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Property  of  the 

Lancaster  City  and  County 
Medical  Society 


No. 


1118 


Received,  

Title,  c<jLU..:ll.. 


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THE 


AMERICAN  JOURNAL 

OF  THE 

MEDICAL  SCIENCES. 

EDITED  BY 

ISAAC  HAYS,  M.D., 

FELLOW  OF  THE  PHILADELPHIA  COLLEGE  OF  PHYSICIANS  J  MEMBER  OF  THE 
AMERICAN  MEDICAL  ASSOCIATION  ;  OF  THE  AMERICAN  PHILOSOPHICAL  SOCIETY  ;  OF  THE 
ACADEMY  OF  NATURAL  SCIENCES  OF  PHILADELPHIA  J  ASSOCIATE  FELLOW 
OF  THE  AMERICAN  ACADEMY  OF  ARTS  AND  SCIENCES, 
&C.  &C.  &C. 

NEW  SERIES. 
YOL.  XLV. 


PHILADELPHIA: 
BLANCHARD    AND  LEA. 
1863. 


69471 


Entered  according  to  the  Act  of  Congress,  in  the  year  1863,  by 
BLANCHARD  AND  LEA, 

the  Office  of  the  Clerk  of  the  District  Court  of  the  United  States  in  and  for  the 
Eastern  District  of  the  State  of  Pennsylvania. 


PHILADELPHIA  ! 
COLLINS,  PRINTER. 


&I0.5 

v.4B 
fled. 


TO  READERS  AND  CORRESPONDENTS. 
The  following  works  have  been  received : — 

Medico-Chirurgical  Transactions.  Published  by  the  Royal  Medical  and  Chi- 
mrgical  Society  of  London.  2d  series.  Yol.  XXYII.  London,  1862.  (From 
the  Society.) 

A  System  of  Surgery,  Theoretical  and  Practical,  in  treatises  by  various  authors. 
Edited  by  F.  Holmes,  M.  A.  Cantab.,  Assistant  Surgeon  to  St.  George's  Hos- 
pital, &c.  In  four  volumes.  Yol.  III.  Operative  Surgery;  Diseases  of  the 
Organs  of  Special  Sense,  Respiration,  Circulation;  Locomotion,  and  Innerva- 
tion.   London :  Parker,  Son  &  Bourn,  1862.    (From  the  Editor.) 

The  Renewal  of  Life :  Clinical  Lectures  illustrative  of  the  Restorative  System 
of  Medicine,  given  at  St.  Mary's  Hospital.  By  Thomas  K.  Chambers,  M,  D., 
F.  R.  C.  P.,  Physician  to  St.  Mary's  Hospital,  &c.  &c.  London:  John  Churchill, 
1862.    (From  the  Author.) 

Addresses  delivered  by  Dr.  Burrows,  Dr.  Walsh,  Mr.  Paget,  and  Dr.  Shar- 
fey,  at  the  thirtieth  annual  meeting  of  the  British  Medical  Association  held  at 
the  Royal  College  of  Physicians,  London,  in  1862.    London,  1862. 

Medical  Communications  of  the  Massachusetts  Medical  Society.  Yol.  X., 
No.  2,  1862.    2d  series.    Yol.  YL,  Pt.  2.    Boston,  1862. 

Bulletin  of  the  New  York  Academy  of  Medicine.  Yol.  I.  Nos.  20  to  37, 
inclusive.    The  first  19  Nos.  have  not  been  received. 

The  Hospital  Steward's  Manual:  for  the  instruction  of  Hospital  Stewards, 
Ward  Masters,  and  Attendants,'  in  their  several  duties.  Prepared  in  strict 
accordance  with  existing  regulations  and  the  customs  of  service  in  the  armies 
of  the  United  States  of  America,  and  rendered  authoritative  by  order  of  the 
Surgeon  General.  By  Joseph  Janvier  Woodward,  Assistant  Surgeon  U.  S.  A., 
Member  of  the  Acad,  of  Nat.  Sci.  of  Philad.,  &c.  Philadelphia,  J.  B.  Lippin- 
cott  &  Co.,  1862. 

Anatomy  of  the  Arteries  of  the  Human  Body,  Descriptive  and  Surgical, 
with  the  Descriptive  Anatomy  of  the  Heart.  By  John  Hatch  Power,  M.  D., 
F.  R.  C.S.,  Professor  of  Descriptive  and  Practical  Anatomy  in  Royal  College 
of  Surgeons,  &c.    Philadelphia:  J.  B.  Lippincott  &  Co.,  1862. 

The  Institutes  of  Medicine.  By  Martyn  Paine,  A.M.,  M.  D.,  LL.  D.,  Pro- 
fessor of  the  Institutes  of  Medicine  and  Materia  Medica  in  University,  city  of 
New  York.    Seventh  edition.    New  York,  1862.    (From  the  Author.) 

The  Physician's  Handbook  of  Practice  for  1863.  By  Wm.  Elmer,  M.  D. 
New  York :  W.  A.  Townsend,  1862. 

Dentition  and  its  Derangements.  A  Course  of  Lectures  delivered  in  the  New 
York  Medical  College.  By  AJ  Jacobi,  M.  D.,  Professor  of  Infantile  Pathology 
and  Therapeutics,  &c.    New  York :  Bailliere  Brothers,  1862. 

A  few  Remarks  on  the  Primary  Treatment  of  Wounds  received  in  Battle :  a 
Report  to  the  Surgeon-General  of  Massachusetts.  By  George  H.  Gay,  M.  D.> 
Surgeon  to  the  Massachusetts  General  Hospital.  Boston :  David  Clapp,  1862. 
(From  the  Author.) 


8 


TO  READERS  AND  CORRESPONDENTS. 


On  Medical  Provision  for  Railroads,  as  a  Humanitarian  Measure,  as  well  as 
a  source  of  Economy  to  the  Companies.  By  Edmund  S.  F.  Arnold,  M.  D.,  &c. 
&c.    New  York:  Bailliere  Brothers,  1862. 

Medicine  a  Science.  An  Address  delivered  before  the  Medical  Class  of  the 
University  of  Vermont,  June  9,  1862.  By  Charles  L.  Allen,  M.  D.  Bur- 
lington, 1862.    (From  the  Author.) 

Introductory  Address  to  the  Course  of  Medical  Lectures,  at  Georgetown  Col- 
lege, November  3,  1862.  By  Silas  L.  Loomis,  M.  D.,  Professor  of  Physics  and 
Chemistry.    Washington,  1862. 

Lecture  on  the  Medical  History  of  the  Philadelphia  Almshouse.  Delivered 
at  the  opening  of  the  Clinical  Lectures,  October  15, 1862.  Dy  D.  Hayes  Agnew, 
M.  D.  Published  by  request  of  the  Board  of  Guardians.  Philadelphia,  1862. 
(From  the  Author.) 

Catalogue  of  the  Trustees,  Overseers,  Faculty,  and  Students  of  the  Berkshire 
Medical  Institution  for  the  year  1862,  and  of  the  Graduates  and  Honorary 
Graduates  since  its  incorporation  in  1823.    Pittsfield,  Mass.,  Oct.  1862. 

The  following  Journals  have  been  received  in  exchange: — 

Annales  Medico-Psychologiques.  Redige  par  MM.  les  Docteurs  Baillarger, 
Cerise,  et  Moreau  (de  Tours).    July,  1862. 

Gazette  Medicale  de  Paris.  Eedacteur  en  chef,  Jules  Guerin.  Nos.  31,  33, 
34,  35,  36,  37,  38,  39,  40,  41,  42,  43.  1862. 

Gazette  Hebdomadaire  de  Medecine  et  de  Chirurgie.    Redacteur  en  chef,  A. 
Dechambre.    Nos.  31,  32,  33,  34,  35,  36,  37,  38,  39,  40,  41,  42,  43.  1862. 
,     Journal  de  Medecine  de  Bordeaux.    Redacteur  en  chef,  M.  Costes.  April, 
May,  June,  July,  August,  1862. 

The  Dublin  Quarterly  Journal  of  Medical  Science.  August,  November,  1862. 

Edinburgh  Medical  Journal.  August,  September,  October,  November,  De- 
cember, 1862. 

The  British  and  Foreign  Medico-Chirurgical  Review.    October,  1862. 

The  Medical  Critic  and  Psychological  Journal.  Edited  by  Forbes  Winslow, 
M.  D.    October,  1862. 

Guy's  Hospital  Reports.  Edited  by  Samuel  Wilks,  M.  D.,  and  Alfred  Po- 
land.   Third  series,  Vol.  VIII.    October,  1862. 

Glasgow  Medical  Journal.    October,  1862. 

The  London  Medical  Review.  August,  September,  October,  November,  1862. 

British  Medical  Journal;  being  the  Journal  of  the  British  Medical  Associa- 
tion. February,  March,  April,  May,  June,  July,  August,  September,  October, 
November,  1862. 

The  Stethoscope;  a  Quarterly  Review  of  the  Modern  Practice  in  Consump- 
tion and  Chest  Diseases.    October,  1862. 

The  Madras  Quarterly  Journal  of  Medical  Science.    July,  1862. 

The  British  American  Journal.  Edited  by  Archibald  Hall,  M.  D.  Septem- 
ber, October,  November,  1862. 

The  Boston  Medical  and  Surgical  Journal.  Edited  by  Samuel  L.  Abbot, 
M.  D.    October,  November,  December,  1862. 

American  Medical  Times.    October,  November,  December,  1862. 

The  Cincinnati  Lancet  and  Observer.  Edited  by  Edward  B.  Stevens,  M.  D., 
and  John  A.  Murphy,  M.  D.    October,  December,  1862. 


TO  READERS  AND  CORRESPONDENTS. 


9 


The  American  Journal  of  Insanity.  Edited  by  the  Medical  Officers  of  the 
New  York  State  Lunatic  Asylum.    October,  1862. 

The  Chicago  Medical  Journal.  Edited  by  Daniel  Brainard,  M.  D.,  and  J. 
A.  Allen,  M.  D.    October,  November,  December,  1862. 

The  Chicago  Medical  vExaminer.  Edited  by  N.  S.  Davis,  M.  D.  September, 
October,  1862. 

The  Medical  and  Surgical  Eeporter.  Edited  by  S.  W.  Butler,  M.  D.,  and 
E.  J.  Levis,  M.  D.    October,  November,  1862. 

American  Medical  Monthly.  Edited  by  J.  H.  Douglas,  M.  D.  September, 
October,  1862. 

Buffalo  Medical  and  Surgical  Journal.  Edited  by  Julius  F.  Miner,  M.  D. 
October,  December,  1862. 

The  Pacific  Medical  and  Surgical  Journal.  Edited  by  James  Blake,  M.  D. 
August,  1862. 

The  San  Francisco  Medical  Press.  Edited  by  L.  C.  Lane,  M.  D.  October, 
1862. 

The  Cincinnati  Medical  and  Surgical  News.  Edited  by  Drs.  A.  H.  Baker 
and  J.  A.  Tn acker.    September,  October,  1862. 

American  Journal  of  Pharmacy.  Published  by  authority  of  the  Philadelphia 
College  of  Pharmacy.  Edited  by  Wm.  Proctor,  Jr.,  Professor  of  Pharmacy. 
November,  1862. 

The  Dental  Cosmos.  Edited  by  J.  D.  White,  D.  D.  S.,  J.  H.  McQuillan, 
D.  D.  S.,  and  Geo.  J.  Zeigler,  M.  D.    October,  November,  December,  1862. 

The  American  Druggists'  Circular  and  Chemical  Gazette.  October,  Novem- 
ber, December,  1862. 

The  American  Journal  of  Science  and  Art.  Edited  by  Profs.  B.  Silliman 
and  B.  Silliman,  Jr.,  and  Jas.  D.  Dana.    November,  1862. 


Communications  intended  for  publication,  and  Books  for  Review,  should  be  sent, 
free  of  expense,  directed  to  Isaac  Hays,  M.  D.,  Editor  of  the  American  Journal  of  the 
Medical  Sciences,  care  of  Messrs.  Blanchard  &  Lea,  Philadelphia.  Parcels  directed 
as  above,  and  (carriage  paid)  under  cover,  to  Messrs.  Triibner  &  Co.,  Booksellers, 
No.  60  Paternoster  Row,  London,  E.  C. ;  or  M.  Hector  Bossange,  Lib.  quai  Voltaire, 
No.  11,  Paris,  will  reach  us  safely  and  without  delay.  We  particularly  request 
the  attention  of  our  foreign  correspondents  to  the  above,  as  we  are  often  subjected 
to  unnecessary  expense  for  postage  and  carriage. 

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Locust  Street. 

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addressed  exclusively  to  the  publishers,  Messrs.  Blanchard  &  Lea. 

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and  all  communications  for  it  should  be  made  to  the  publishers. 

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previous  month. 


CONTENTS 


AMERICAN  JOURNAL 

OF  THE 

MEDICAL  SCIENCES. 

NO.  LXXXIX.  NEW  SERIES. 
JANUARY,  1863. 


ORIGINAL  COMMUNICATIONS. 

MEMOIRS  AND  CASES. 

ART.  PAGE 

I.  Paracentesis  Thoracis  ;  a  resume  of  twelve  years'  expeiience.  By  Henry 
I.  Bowditch,  M.D.  (Read  before  the  Boston  Society  for  Medical  Ob- 
servation.)      .       .       .       .   (    .  17 

II.  Conservative  Medicine  as  applied  to  Therapeutics.  By  Austin  Flint, 
M.  D.,  Professor  of  the  Principles  and  Practice  of  Medicine  in  the  Bel- 
levue  Hospital  Medical  College,  and  in  the  Long  Island  College  Hospital.  22 

III.  Report  of  Fifty-seven  Cases  of  Amputations,  in  the  Hospitals  near 
Sharpsburg,  Md.,  after  the  Battle  of  Antietam,  September  17,  1862.  By 

G.  J.  Fisher,  M.  D.,  of  Sing  Sing,  N.  Y  44 

IY.  On  Trismus  Nascentium.  By  Greensville  Dowell,  M.  D.,  Columbia, 
Brazoria  County,  Texas  51 

V.  Tracheotomy  for  the  Removal  of  Foreign  Bodies  from  the  Air-Passages. 
With  Cases.    By  A.  G.  Walter,  Surgeon,  Pittsburg,  Pa.       .       .  .56 

YL  A  New  Method  of  Performing  Tracheotomy,  with  two  Illustrative 
Cases.    By  J.  H.  Bill,  Assistant  Surgeon  U.  S.  A.         .       .       .  .63 

YII.  Case  of  Primary  Pyaemia.  By  James  Blake,  M.  I).,  F.  R.  C.  S.,  San 
Francisco,  California  67 

Y1II.  Ligation  of  the  Subclavian  of  a  Negro.  Death  of  the  Patient,  with 
some  Inquiries  as  to  its  Cause.  By  Rufus  King  Browne,  M.  D.,  late 
Brigade  Surgeon  U.  S.  Y.,  Surgeon-in-chief  U.  S.  General  Hospital,  New 
Orleans  70 

IX.  Dislocation  of  the  Left  Shoulder  reduced  by  Manipulation,  without  the 
Employment  of  Anaesthetics  or  other  Remedies.    By  Charles  H.  Pile, 

M.  D.,  Assistant  Surgeon  U.  S.  N   .       .  .75 

X.  Hemorrhage  following  the  Extraction  of  a  Tooth.  By  George  S.  D. 
Anderson,  M.  D.,  of  Rapides,  Louisiana.  76 

XL  Premature  Delivery,  with  very  rare  Presentation  of  the  Foetus.  By 
W.  T.  Owen,  M.  D.,  of  Louisville,  Ky  77 

XII.  Case  of  Placenta  Praevia.    By  Wm.  T.  Taylor,  M.  D.  .  .78 

XIIL  Case  of  Injury  of  the  Neck.  By  Redfern  Davies,  Esq.,  M.  R.  C.  S.,  of 
Birmingham,  England,  now  acting  Assistant  Surgeon  U.  S.  A.  (Brought 
before  the  Brodie  Med.-Chirurg.  Society,  Frederick  City,  Md.)      .       .  79 


12 


CONTENTS. 


TRANSACTIONS  OF  SOCIETIES. 

ART.  PAGE 
• 

XIV.  Summary  of  the  Transactions  of  the  College  of  Physicians  of  Phila- 
delphia '  81 

Intra-uterine  Hydrocephalus;  Breech  Presentation;  Craniotomy; 
Recovery  of  Mother.    By  Dr.  Corse  81 

Remarkable  Case  of  the  Co-existence  of  Tetanus  and  Paralysis.  By 
Dr.  Hunt  82 

Colloid  Cancer  of  the  Omentum,  Mesentery,  &c. ;  Scirrhus  of  the 
Stomach  and  Uterus;  Colloid  of  the  Ovaries.    By  Dr.  Levick.    .  84 

Cases  of  Stone  in  the  Bladder.    By  Dr.  Gilbert  85 

Hypodermic  Injections  of  Sulphate  of  Morphia  used  daily  for  five 
months,  twice  daily  for  three  months,  and  three  times  daily  for  six 
weeks,  with  great  relief  to  the  patient,  and  with  no  unpleasant 
sequelae.  87 


REVIEWS. 

XV.  Consumption ;  its  Early  and  Remediable  Stages.  By  Edward  Smith, 
M.  D.,  F.  R.  S.,  Assistant  Physician  to  the  Hospital  of  Consumption  and 
Diseases  of  the  Chest,  Brompton,  etc.  etc.  London :  Walton  &  Maberly, 
1862.    12mo.  pp.  447   91 

XVI.  On  Asthma ;  its  Pathology  and  Treatment.    By  Henry  Hyde  Salter, 

M.  D.,  F.  R.  S.    London,  1860.    8vo.  pp.  372   97 

XVII.  General  Report  of  the  Commission  appointed  for  Improving  the 
Sanitary  Condition  of  Barracks  and  Hospitals.  (Presented  to  both  Houses 

of  Parliament  by  command  of  Her  Majesty.    1861.)      ....  112 

XVIII.  The  New  Sydenham  Society.  Vol.  XI.  Selected  Monographs : 
Czermak  on  the  Practical  Uses  of  the  Laryngoscope ;  Dusch  on  Throm- 
bosis of  the  Cerebral  Sinuses ;  Schroeder  Van  der  Kolk  on  Atrophy  of 
the  Brain  ;  Radicke  on  the  Application  of  Statistics  to  Medical  Inquiries; 
and  Esmarch  on  the  Uses  of  Cold  in  Surgical  Practice.  London,  1861. 
8vo.  pp.  329.    .  -   121 

XIX.  Guy's  Hospital  Reports.  Edited  by  Samuel  Wilks,  M.  D.,  and  Alfred 
Poland.  Third  series.  Vol.  VIII.   London  :  John  Churchill,  1862.  8vo. 

pp.  325   125 


BIBLIOGRAPHICAL  NOTICES. 

XX.  Transactions  of  State  Medical  Societies. 

1.  Medical  Communications  of  the  Massachusetts  Medical  Society,  at 
its  Annual  Meeting,  held  May,  1862.  8vo.  pp.  216.  Second  series. 
Vol.  VI.,  Part  II.    Boston,  1862. 

2.  Medical  Communications  with  the  Proceedings  of  the  Seventh  Annual 
Convention  of  the  Connecticut  Medical  Society,  held  at  Bridgeport, 
May  28  and  29,  1862.    New  series,  Vol.  I.,  No.  3.   New  Haven,  1862.  139 

XXI.  Reports  of  American  Institutions  for  the  Insane. 

1.  Of  the  Pennsylvania  Hospital  for  the  Insane,  for  the  year  1861. 

2.  Of  the  Friends'  Asylum,  for  the  fiscal  year  1861-62. 

3.  Of  the  Western  Pennsylvania  Hospital,  for  the  year  1861. 

4.  Of  the  Bloomingdale  Asylum,  for  the  year  1861. 

5.  Of  the  McLean  Asylum,  for  the  year  1861. 

6.  Of  the  Massachusetts  State  Hospital,  at  Northampton,  for  the  fiscal 
year  1860-61. 

7.  Of  the  Longview  Asylum,  for  the  year  1861. 

8.  Of  the  New  Hampshire  Asylum,  for  the  fiscal  year  1861-62.     .       .  148 


CONTENTS. 


13 


ART. 


PAGE 


XXII.  Border  Lines  of  Knowledge  in  some  Provinces  of  Medical  Science^ 
An  Introductory  Lecture,  delivered  before  the  Medical  Class  of  Harvard'* 
University,  November  6th,  1861.    By  Oliver  Wendell  Holmes,  M.  1)., 
Parkman  Professor  of  Anatomy  and  Physiology.    Ticknor  &  Fields : 
Boston,  1862.    8vo.  pp.  80  157 

XXIII.  The  Sanitary  Condition  of  the  Army  of  the  United  States.  By 
Edward  Jarvis,  M.  D.,  of  Dorchester,  Mass.   8vo.  pp.  36.   From  the  At- 


XXIY.  Dentition  and  its  Derangements.  A  Course  of  Lectures  delivered 
in  the  New  York  Medical  College.  By  A.  Jacobi,  M.  D.,  Professor  of 
Infantile  Pathology  and  Therapeutics,  etc.   12mo.  pp.  172.   New  York : 


XXY.  Addresses  delivered  by  Dr.  Burrows,  Dr.  Walshe,  Mr.  Paget,  and 
Dr.  Sharpey,  at  the  Thirtieth  Annual  Meeting  of  the  British  Medical 
Association,  held  at  the  Royal  College  of  Physicians,  London,  in  1862. 
London,  1862.    12mo.  pp.  98  169 

XXYI.  Pathological  and  Practical  Observations  on  Diseases  of  the  Abdo- 
men, comprising  those  of  the  Stomach  and  other  parts  of  the  Alimentary 
Canal,  (Esophagus,  Caecum,  Intestines,  and  Peritoneum.  By  S.  0.  Haber- 
shon,  M.  D.,  Lond.,  F.  R.  C.  P.,  Senior  Assistant  Physician  to  Guy's  Hos- 
pital, &c.  &c.  Second- edition,  considerably  enlarged  and  revised.  Lon- 
don :  John  Churchill,  1862.    8vo.  pp.  594.     .       ....       .  .174 

XXYII.  Anatomy  of  the  Arteries  of  the  Human  Body,  Descriptive  and 
Surgical,  with  the  Descriptive  Anatomy  of  the  Heart.  By  John  Hatch 
Power,  M.  D.,  Fellow,  and  Member  of  Council,  of  the  Eoyal  College  of 
Surgeons  ;  Professor  of  Descriptive  and  Practical  Anatomy  in  the  Royal 
College  of  Surgeons ;  Surgeon  to  the  City  of  Dublin  Hospital,  etc.  Au- 
thorized and  adopted  by  the  Surgeon-General  of  the  United  States  Army 
for  use  in  Field  and  General  Hospitals.  Philadelphia :  J.  B.  Lippincott 
&  Co.,  1862.    12mo.  pp.  401  178 

XXYIII.  The  Institutes  of  Medicine.  By  Martyn  Paine,  M.  D.,  LL.  D., 
Professor  of  the  Institutes  of  Medicine  and  Materia  Medica  in  the  Uni- 
versity of  the  City  of  New  York,  etc.  etc.  etc.  Seventh  edition.  8vo. 
pp.  1130.    New  York,  1862.    Harper  &  Brothers  181 

XXIX.  The  Hospital  Steward's  Manual:  for  the  Instruction  of  Hospital 
Stewards,  Ward  Masters,  and  Attendants,  in  their  several  Duties.  Pre- 
pared in  strict  accordance  with  existing  regulations  and  the  customs  of 
service  in  the  armies  of  the  United  States  of  America,  and  rendered  au- 
thoritative by  order  of  the  Surgeon-General.  By  Joseph  Janvier  Wood- 
ward, M.  D.,  Assistant  Surgeon  U.  S.  A.,  Member  of  the  Academy  of 
Natural  Sciences  of  Philadelphia,  etc.    Philadelphia :  J.  B.  Lippincott 

&  Co.,  1862.    12mo.  pp.  324   182 

XXX.  A  few  Remarks  on  the  Primary  Treatment  of  Wounds  received  in 
Battle  ;  a  Report  to  the  Surgeon-General  of  Massachusetts.  By  George 
H.  Gay,  M.  D.,  Surgeon  at  the  Massachusetts  General  Hospital.  Boston, 
1862.    8vo.  pp.  8,  182 


lantic  Monthly  for  October,  1862, 


161 


1862.    Bailliere  Brothers. 


163 


14 


CONTENTS. 


QUARTERLY  SUMMARY 

OF  THE 

IMPROVEMENTS  AND  DISCOVERIES  IN  THE 
MEDICAL  SCIENCES. 

FOREIGN  INTELLIGENCE. 
Anatomy  and  Physiology. 


page 

1.  The  Deep  Origin  of  the  Facial 
Nerve.    By  M.  A.  Vulpian.     .  183 

2.  Epithelium  of  the  Air-Cells.  By 
Dr.  C.  J.  Eberth.      .       .       .  183 


PAGE 

3.  Identity  of  Haemato'idin  and  Bi- 
lifulvin.    By  Dr.  Max  Jaffe.  .184 


Materia  Medic. 

4.  Action  and  Uses  of  Codeia.  By 
Dr.  Aran.         .  184 

5.  Use  of  Malt  and  Beer  in  Thera- 
peutics 185 

6.  On  some  Local  Anaesthetics.  By 
Messrs.  Dyce,  Duckworth,  and 
Richard  Davy  186 

7.  Phlorydzine.    By  Dr.  De  Ricci.  188 

8.  Carba'zotate  of  Iron.  By  Mr.  H. 

N.  Draper.       .       .  .188 


and  Pharmacy. 

9.  Iodized  Coffee  of  Hutet.  .       .  190 

10.  Syrup  of  Carbonate  of  Iron. 

By  Mr.  H.  N.  Draper.      .       .  190 

11.  The  Permanent  Voltaic  Cur- 
rent as  a  Therapeutic  Agent. 

By  Dr.  Hiffelsheim.  .       .  .190 

12.  Electro-galvanism  or  Galvanic 
Electricity.  By  Dr.  W.  H.  Sand- 
ham.   191 


Medical  Pathology  and  Therapeutics,  and  Practical  Medicine. 


13.  Further  Observations  on  Ty- 
phus and  Typhoid  Fevers,  as  seen 
in  Dublin,  especially  the  united 
form  which  they  assumed  during 
the  first  half  of  the  year  1862. 

By  Mr.  Henry  Kennedy.   .  .192 

14.  Treatment  of  Typhoid  Type  of 

Fe  ver.    By  Dr.  H.  Kennedy.    .  193 

15.  Epidemic  of  Typhus  in  Iceland. 

By  Dr.  John  Hjaltelin.     .       .  194 

16.  Disinfecting  Treatment  of  Ty- 
.    phus  and  Typhoid  Fevers.  By 

Dr.  John  Hjaltelin    .       .  .196 

17.  Treatment  of  Delirium  Tre- 
mens.   By  Prof.  Laycock.        .  198 

18.  Anaesthesia  caused  by  Diseases 

of  the  Lungs.    By  M.  Bouchut.  201 

19.  Therapeutics  of  Consumption. 

By  Dr.  Cotton.        .       .  .201 

20.  Pleuritic  Effusions,  viewed  in 
Relation  to  Thoracentesis.  By 
Dr.  Henley  Thorp.    .       .  .202 


21.  On  Tobacco  as  a  Cause  of  An- 
gina Pectoris.    By  Dr.  Beau.  .  205 

22.  Rheumatic  Pericarditis  and 
Endocarditis.    By  Dr.  Jos.  Bell.  207 

23.  The  Physiology  and  Pathology 
of  the  Supra-renal  Capsules.  By 
Dr.  Harley  207 

24.  Morbus  Addisonii.  By  Dr. 
Wilks  208 

25.  Bronzed  Skin  Successfully 
Treated.    By  Thos.  Taylor,  Esq.  208 

26.  Diabetes  Mellitus  ending  in 
Phthisis.    By  Dr.  Willett.       .  209 

27.  New  Means  of  Distinguishing 
Diabetic  Urine.   By  M.  Paillon.  210 

28.  Production  of  Carbonate  of 
Ammonia  in  the  Blood  in  Urae- 
mic  Poisoning.  By  Dr.  Alex. 
Petroff.  210 

29.  Membranous  Cysts  in  the  In- 
terior of  the  Urinary  Bladder. 

By  Dr.  R.  Knox.      .       .       .  211 


CONTENTS. 


15 


30.  Inversion  of  the  Urinary  Blad- 
der through  the  Urethra,  with 
large  Prolapsus  of  the  Rectum, 
in  a  Female  Child.  By  Dr. 
Beatty.  213 

31.  Verruca  Necrogenica.  By  Dr. 
Wilks  213 


32.  Eczema  of  the  External  Audi- 
tory Meatus.  By  Dr.  T.  M'Call 
Anderson.         ....  214 

33.  An  unusual  Abnormal  Condi- 
tion of  the  Mucous  Membrane 
of  the  Tongue  and  Mouth.  By 
Dr.  Neligan.     .       .    ■  .  .215 


Surgical  Pathology  and  Therapeutics,  and  Operative  Surgery. 


34.  Eapid  Spontaneous  Cure  of 
Popliteal  Aneurism.  By  Camp- 
bell de  Morgan,  Esq.        .  .216 

35.  Garibaldi's  Wound.  By  M. 
Nelaton  218 

36.  Old  Gunshot  Injury  of  the  Ti- 
bia ;  Eecent  Fracture  of  the  Fe- 
mur.   By  Mr.  Tufnell.      .       .  218 

37.  Blow  on  the  Head ;  Sudden 
Death  two  years  after  from  the 
Injury.    By  M.  de  Closmadeuc.  219 

38.  Reunion  of  Iutra- capsular 
Fractures  of  the  Femur.  By  M. 
Fabri.  219 

39.  Portion  of  Food  Impacted  in 

the  Larynx.    By  Mr.  Spence.  .  220 

40.  Tracheotomy  Tube  dropped 
into  Left  Bronchus.  By  Mr. 
Spence  220 

41.  Use  of  Nicotia  in  Tetanus  and 
in  Poisoning  by  Strychnia.  By 
Prof.  S.  Haughton.  .       .  .220 

42.  On  the  Use  of  Iodine  Injections 
in  Large  Acute  Abscesses.  By 

M.  Cosmag-Dumenze.       .       .  221 

43.  Treatment  of  Chronic  Swelling 
of  the  Bursa  Patellar  by  Punc- 
ture and  the  Injection  of  a  Solu- 
tion of  Iodine.  By  Dr.  Robert 
Kirkwood  222 

44.  Subcutaneous  Treatment  of 
Boils  and  Carbuncles.    By  Mr. 

J.  G.  French  222 


45.  How  to  Relieve  Pain  in  Dis- 
eased Bladder.  ....  223 

46.  Deafness  Consequent  on  Rheu- 
matism; Noise  in  the  Ears.  By 
Dr.  Delioux  223 

47.  Difficulties  and  Dangers  attend- 
ing Catheterism  of  the  Eusta- 
chian Tube.    By  M.  Triquet.    .  224 

48.  Double  Inguinal  Hernia  on  the 
same  Side.    By  Prof.  Engel.    .  220 

49.  What  Direction  does  a  Hernial 
Sac  take  when  Reduced?  By 
Prof.  Engel  226 

50.  Metallic  Sutures.    By  Mr.  W. 

N.  Chipperfield.        .       .  .226 

51.  Utility  and  Superiority  of  Me- 
tallic Sutures.    By  M.  Oilier.   .  226 

52.  Horsehair  as  a  Substitute  for 
Wire  for  Sutures.  By  Mr.  T. 
Smith.  227 

53.  Encysted  Tumours.  By  Dr. 
Henley  Thorp  229 

54.  Fibrous  Tumours  of  the  Iliac 
Fossa.    By  M.  Nelaton.  .       .  231 

55.  Necrosis.  By  Mr.  Thos.  Wor- 
mald  232 

56.  Ovariotomy.  By  Dr.  Robt.  Lee.  232 

57.  Ovariotomy  in  Ireland.  By 
Dr.  Kidd  239 

58.  Ovarian  Dropsy  cured  by  Io- 
dine Injections.    By  Dr.  B alien.  239 


O  PHTH ALMOLOGY. 


59.  Inferior  Section  of  Cornea  for  61.  Ophthalmic   Ointments.  By 
Extraction  of  Cataract.   By  Mr.  Mr.  W.  White  Cooper.     .  .243 
Ernest  Hart                             240  62.  Opium  in  Conjunctivitis.  By 

60.  Some  Affections  of  Vision  ap-  Mr.  W.  White  Cooper.     .  .243 
parently  of  Syphilitic  Origin. 

By  Dr.  R.  Hibbert  Taylor.       .  240 


Midwifery. 


63.  Painless  Parturition.    By  Dr.  65.  Undescribed  Cause  of  Delay  in 
George  Smith                           244  Labour.    By  Dr.  Jas.  Sidey.    .  246 

64.  Artificial  Delivery  in  Extremis.  66.  Use  of  the  Forceps  in  Tedious 

By  Dr.  Belluzi.        .       .       .  245  Labour.    By  Dr.  Hamilton.     .  246 


16 


CONTENTS. 


PAGE 

67.  Post-partum  Hemorrhage.  By 
Dr.  Hamilton  248 

68.  New  Transfusion  Apparatus. 

By  Dr.  Hamilton.     .       .  .248 

69.  Repeated  Twin  Births.    By  J. 

L.  Brittain  251 

70.  Extrauterine  Pregnancy.  By 
Dr.  Brandt  251 

71.  Extra  Uterine  Fcetation;  the 
Foetus  in  the  Sac  of  the  Hernia. 
ByHerr  W.  Mttller.  .       .  .252 

72.  Retroversion  of  a  Pregnant 
Uterus.    By  Dr.  Bruce.    .       .  252 

73.  Dr.  Hodge's  Pessary  for  Re- 


troversion of  the  Uterus.  By 
Dr.  Churchill  254 

74.  The  Changes  of  Body-weight  in 
Pregnant,  Parturient,  and  Puer- 
peral Women.    By  Dr.  Gassner.  254 

75.  The  Organic  Connection  of  the 
Fallopian  Tube  with  the  Ovary. 

By  Dr.  Panck  255 

76.  Ovarian  Cyst  Discharging 
through  Vagina.   By  Dr.  Irvine.  255 

77.  Diseased  Placenta.  By  Dr. 
McClintock  256 

78.  Apncea  Neonatorum.  By  Mr. 
Greaves  256 


Medical  Jurisprudence  and  Toxicology. 


79.  New  Cause  of  Death  under 
Chloroform.  By  Dr.  G.  W.  Bal- 
four.  257 

80.  Tannin  as  an  Antidote  to 
Strychnia.    By  Prof.  Kurzak.  .  258 

81.  Detection  of  Blood  Stains.  By 
Dr.  Erdmann  258 

82.  The  Haemine  Crystals  in  differ- 
ent Animals.   By  Dr.  Wilbrand.  259 

83.  Poisoning  by  Nitrate  of  Strych- 


nia, Acetate  of  Morphia,  Bitter- 
Almond  Water,  and  Chloroform. 
By  Dr.  Tschepke.     .       .  .259 

84.  Poisoning  by  Sulphuric  Acid. 

By  Antonio  Cozzi.    .       .       .  261 

85.  Poisoning  by  Bitter  Almonds, 
with  Iodide  of  Iron.  By  M.  Tos- 
cani  261 

86.  Case  of  Rape  during  Sleep.    .  261 


AMERICAN  INTELLIGENCE. 

Original  Communications. 

Abdominal  Carcinoma  resulting  Death  during  Convalescence  in  Ty- 

in  Artificial  Anus  in  the  Upper  phoid  Fever  from  over-eating. 

Third  of  the  Ileum.    By  D.  Lea-  By  Jas.  L.  Ord,  M.  D.      .       .  266 

sure,  M.D  263 


Ligation  of  the  Subclavian  Artery. 
By  Dr.  H.  N.  Bennett.  . 

Vinegar  as  an  Anti-Scorbutic  By 
Dr.  Alex.  McBride.  .       .       .  zo  i 

Oakum  as  a  Substitute  for  Lint  in 
Gunshot  and  other  Suppurating 
Wounds.  By  Dr.  W.  S.  W. 
Ruschenberger.        .       .       .  268 

Croup;  Tracheotomy;  Fatal  Re- 
sult.   By  Dr.  Jacobi.       .       .  269 


:stic  Summary. 

j  Black  Calculus  from  the  Kidney. 

266  j    By  Dr.  White  270 

Case  of  Poisoning  from  the  Pollen 
of  the  Common  Yellow  Tiger 
Lily.  By  Dr.  Jeffries  Wyman.  271 
Can  Pregnancy  follow  Defloration 
in  Rape,  when  Force  simply  is 
used?  By  Dr.  E.  S.  F.  Arnold.  272 
Rupture  of  Uterus  ;  Csesarean  Sec- 
tion.   By  Dr.  L.  R.  Holmead.  272 


THE 

AMERICAN  JOURNAL 
OF  THE  MEDICAL  SCIENCES 

FOR    JANUARY    1  8  6  3. 


Art.  I. — Paracentesis  Thoracis;  a  resume  of  twelve  years1  experience. 
By  Henry  I.  Bowditch,  M.  D.  (Read  before  the  Boston  Society  for 
Medical  Observation.) 

In  the  American  Journal  of  the  Medical  Sciences,  April,  1852,  I  pub- 
lished an  article  on  Paracentesis  Thoracis,  with  cases.  In  January,  1854, 
I  gave  in  the  American  Medical  Monthly  an  analysis  of  twenty-five  cases 
of  the  same.  Still  later  I  made  further  statements  on  the  subject  in  the 
Boston  Med.  and  Surg.  Journal,  1851,  and  now  I  wish  to  give  to  the 
Society  a  brief  resume  of  the  principal  results  of  the  operation,  as  per- 
formed 150  times  on  15  persons  during  a  period  of  nearly  twelve  years, 
viz.,  from  April  IT,  1850,  to  Dec.  IT,  1861. 

During  the  above  period  I  have  operated  150  times  on  15  persons,  and 
have  seen  other  gentlemen  operate  on  10  more,  making  160  operations  on 
85  persons. 

Innocuousness  of  the  operation.— I  have  never  seen  the  least  permanent 
evil  resulting  from  any  operation,  and  only  the  slightest  temporary  difficul- 
ties, such  as  pain,  slight  dyspnoea,  stricture,  or  cough,  &c.  This,  I  think, 
shows  the  innocuousness  of  the  operation  by  means  of  the  exploring  trocar 
and  suction  pump,  as  suggested  by  Dr.  Wyman. 

Frequency  of  the  operation. — One  lady  (case  formerly  reported)  I  tapped 
9  times  during  8 J  months;  commencing  when  she  was  4j  months  pregnant, 
and  in  whom  the  orthopncea  was,  several  times,  so  great  that  death,  I  have 
no  doubt,  would  have  supervened  within  twenty-four  hours,  if  the  operation 
had  not  been  performed.  She  is  now  tolerably  well,  but  with  a  contracted 
chest,  as  is  usual  in  chronic  pleurisy. 

In  striking  contrast  with  this  case,  as  it  regards  the  frequency  of  the 
operation,  while  resembling  it  in  the  number  of  times  it  was  performed, 
No.  LXXXIX.— Jan.  1863.  *  2 


18 


Bow  ditch,  Paracentesis  Thoracis. 


was  the  unique  case  of  an  elderly  man,  very  recently  under  my  care,  and  In 
which  I  tapped  eight  times  in  six  weeks  !  The  patient  himself,  a  physi- 
cian, earnestly  and  even  solemnly  demanded  of  me  the  operation  as  a  mere 
means  of  relief  to  intense  distress.  As  he  jocosely  remarked  on  one  occa- 
sion, he  considered  it  one  of  his  "  luxuries." 

Cases  in  which  the  patient  recovered  wholly. — Twenty-nine  out  of  the 
seventy-five  patients  got  wholly  well,  apparently  in  consequence,  chiefly,  of 
the  operation.  The  operation  was  performed  generally  when  severe  symp- 
toms were  manifest,  and  I  was  called  in  consultation.  In  a  few,  a  great 
quantity  of  fluid  was  recognized  by  the  physical  signs  ajone,  the  rational 
having  been  slight ;  but,  as  the  disease  was  chronic,  an  operation  was 
deemed  necessary.  In  all  these  cases,  the  operations  seemed  the  first  step 
towards  a  cure. 

The  character  of  the  fluid  and  its  influence  on  the  prognosis. — In  26 
out  of  the  15  serum  was  found;  and  21  of  these  patients  got  wholly  well. 
If  after  the  first  operation  the  fluid  becomes  purulent,  an  almost  certain 
fatal  prognosis  should  be  made.  I  have  seen  six  such  cases.  Four  of  the 
patients  died,  two  were  lost  sight  of,  but,  when  last  seen,  were  failing. 

Pus  was  found  at  the  first  operation  in  twenty-four  cases.  Once,  it  was 
of  the  consistence  of  honey,  but  I  easily  drew  it  through  the  exploring 
tube.  Seven  of  these  patients  recovered  wholly;  seven  died;  nine  were 
relieved  one  or  many  times;  but  they  had  either  a  long  and  tedious  illness, 
terminating  usually  in  phthisis,  or  a  fistulous  opening,  or  a  still  doubtful 
result. 

A  sanguinolent  fluid  at  the  first  puncture  (and  by  that  I  mean  a  dark 
red  thin  fluid,  evidently  stained  with  blood,  though  not  coagulating)  I  con- 
sider almost  certainly  fatal,  and  a  consequence  of  some  malignant  disease 
of  the  lung  or  pleura. 

There  were  seven  of  such  cases.  In  six  the  patients  died.  In  one  there 
was  a  doubtful  result,  but  apparently  fatal  tendencies  were  commencing. 
If  the  fluid  is  found  sanguinolent  at  the  second  or  any  subsequent  punc- 
ture, I  deem  it  of  comparatively  little  importance  towards  the  prognosis. 

A  mixture  of  bloody  purulent  fluid  at  the  first  operation  is  usually  fatal. 
Three  cases,  all  fatal,  occurred. 

A  fetid  gangrenous  fluid  is  very  rare,  only  one  case  having  occurred,  and 
that  fatal ;  but  in  this  case  infinite  relief  from  horrible  orthopnoea  was 
obtained,  and  it  never  returned,  though  the  patient  sunk  and  died  in  a  few 
days.    Gangrenous  pleura  was  found. 

I  have  operated  once  in  pneumo-hydrothorax  with  temporary  relief  and 
comparative  ease  for  several  days.  Many  theoretical  objections  may  be 
urged  against  the  operation  in  such  a  case.  To  such  objections  I  have 
simply  to  answer  that,  as  the  operation  can  do  no  harm  and  may  give  much 
relief,  I  shall  operate  again  in  any  case  where  the  dyspnoea  may  be  so  great 
as  to  require  it. 


1863.]  Bowditch,  Paracentesis  Thoracis.  19 


Gases  where  no  fluid  is  obtained. — Finally,  in  seven  cases  I  got  no  fluid. 
These  cases  occurred  usually  in  the  earlier  operations,  and  the  failure  was 
often  owing,  I  have  no  doubt,  to  the  cautious  and  slow  manner  with  which 
I  plunged  the  trocar  between  the  ribs,  carrying  thus  the  false  membrane  of 
the  pleura  costalis  before  the  instrument  instead  of  piercing  it ;  so  that  a 
valve  was  really  formed  over  the  end  of  the  canula.  At  other  times  I  have 
little  doubt  that  an  error  of  diagnosis  was  made,  and  that  instead  of  a  fluid 
there  was  simply  an  unexpanded  lung  and  thick  false  membranes  on  the 
pleura,  causing  as  much  dulness  on  percussion  and  absence  of  respiration 
as  a  fluid  would  have  done.  The  differential  diagnosis  of  the  two  was  not, 
at  first,  quite  so  easy  as  it  is  now.  Inspection  usually  is  the  test  between 
the  two  conditions ;  the  intercostals  being  distinct,  and  depressed  when  a 
membrane  exists ;  but  very  indistinct  and  level  with  the  ribs,  or,  possibly 
prominent,  when  a  fluid  occupies  the  chest. 

Once  an  immense  tumour  occupied  and  uniformly  distended  one  pleural 
cavity,  and  in  its  course  presented  all  the  phenomena,  natural  and  physical, 
of  simple  pleurisy.  I  tapped  three  times,  viz. :  at  the  back,  side,  and 
front,  at  the  same  visit.    No  evil  followed. 

A  member  of  this  society  asked  me  my  experience  as  to  the  good  results 
or  otherwise  in  operations  on  the  right  side  ;  observing,  at  the  same  time, 
that  one  European  writer  (Trousseau  ?)  contended  that  pleurisy  of  the 
right  side  is  often  or  always  tuberculous.  I  could  not  answer  definitely, 
although  my  impressions  were  against  the  truth  of  the  assertion.  On 
referring  to  the  brief  summaries,  and  not  to  the  original  notes  of  my  cases, 
where  I  find  the  sides  named  in  25  cases,  I  find  that  in  these  the  operation 
was  performed  with  the  following  results  : — 

Pleurisy  of 
Right  side.    Left  side. 

Death.  4  times.    5  times. 

Cure  entire,  without  symptoms  of  phthisis,  ex- 
cept in  one,  but  pleurisy  was  cured  in  that        9     "        4  " 
Doubtful  result  1     "       2  " 

14  11 

These  data  do  not  exactly  answer  the  question  proposed ;  but  if  tubercles 
always  or  more  frequently  exist  in  pleurisy  of  the  right  side,  we  should, 
a  priori,  anticipate  more  unfortunate  terminations  of  the  operation  of 
paracentesis  of  the  right  than  of  the  left  side.  My  experience  proves 
exactly  the  reverse,  and  may  be  expressed,  if  deduced  from  the  above  table, 
as  follows : — 

Of  25  cases,  14  were  of  the  right  side,  11  of  the  left.  Of  the  14  of  the 
right  side,  only  one  person  is  mentioned  as  having  tubercles,  and  in  that 
the  pleurisy  was  cured  and  the  pulmonary  symptoms  mitigated. 

Of  the  14  persons  tapped  in  right  side  28.57  per  cent,  died;  64.28  per 
cent,  were  cured,  and  7.14  per  cent,  remained  doubtful.    Whereas,  of  the 


20 


Bowditch,  Paracentesis  Thoracis. 


[Jan. 


11  cases  of  the  left  side,  45.45  per  cent,  died,  36.36  got  well,  18.18  were 
doubtful. 

In  other  words,  twice  as  many  have  got  well  from  tapping  the  right  as 
the  left ;  and  only  half  as  many  have  had  doubtful  results  from  operations 
on  the  right,  as  in  those  where  the  left  side  has  been  tapped. 

Hereafter,  if  my  cases  are  any  criterion  wherefrom  to  judge,  I  shall 
regard  an  operation  on  the  right  side  as  much  more  favourable  than  one 
on  the  left ;  which  I  can  hardly  think  would  be  the  case  were  all  right  side 
pleurisies  tuberculous. 

When  shall  we  operate? — Experience  teaches  me  to  operate  in  every 
case,  however  recent  or  chronic  may  be  the  attack,  provided  there  is  per- 
manent or  occasional  dyspnoea  of  a  severe  character,  evidently  due  to  the 
fluid.  I  have,  of  course,  more  hope  of  doing  good  where  the  disease  has 
not  been  of  too  long  duration  ;  is  uncomplicated  with  phthisis,  or  any 
other  disease,  and  where,  moreover,  the  amount  of  fluid  seems  directly 
the  cause  of  the  trouble.  I  also  deem  it  best  to  operate  in  any,  even  latent 
cases,  where  the  pleural  cavity  gets  full  of  fluid  ;  and  if,  after  a  reasonable 
amount  of  treatment,  the  fluid  does  not  diminish. 

Where  shall  we  operate? — The  point  originally  chosen  by  Dr.  Wyman 
and  myself,  viz.  :  in  a  line  let  fall  from  the  lower  angle  of  the  scapula, 
and  between  the  9th  and  10th  ribs,  I  deem  the  most  appropriate  point  at 
which  to  make  a  puncture.  I  have,  however,  tapped  under  the  axilla,  or 
in  the  breast,  where  the  case  seemed  to  require  it.  In  selecting  the  pre- 
cise intercostal  space,  on  the  back,  I  usually  choose  one  about  an  inch 
and  a  half  higher  than  the  line,  on  a  level  with  the  lowest  point  at  which 
respiratory  murmur  can  be  heard  in  the  healthy  lung  of  the  other  pleural 
cavity. 

I  never  wait  until  pointing  commences  ;  for  then  I  am  sure  that  pus  will 
be  found.  •  If  pointing  without  opening  has  commenced,  I  do  not  necessa- 
rily tap  in  that  place,  as  recommended  by  the  older  surgeons,  but  seek  the 
most  depending  point  in  the  chest.  While  thus  desiring  to  operate  before 
a  local  distension  shows  itself,  I  dislike  or  refuse  to  tap  where  there  is  con- 
traction of  the  intercostal  muscles ;  and  I  am  certain  of  getting  fluid  only 
where  there  is  distension  or  flattening  of  the  same. 

Objections  to  the  operation. — One  word  on  the  objections  to  the  opera- 
tion :  "  We  may  puncture  the  lung."  "  We  may  let  air  into  the  pleura." 
"  We  may  by  our  strong  suction  injure  the  lung."  "  The  instrument  often 
fails  to  operate."  "  The  connecting  tube  between  the  pump  and  the 
trocar  collapses,  and  thus  checks  the  flow  of  liquid."  "The  liquid  may 
be  too  thick,  and  cannot  be  drawn  through  the  small  canula."  "  We  may 
excite  inflammation  of  the  pleura."  "  The  operation  is  useless,  because 
n  on -tubercular  cases  will  get  well  without;  tubercular  will  die  in  spite  of 
it,"  &c.  &c. 


1863.]  Bowditch,  Paracentesis  Thoracis.  21 


One  and  all  of  these  objections  are  to  me,  with  the  experience  I  have 
had,  simply  absurd.  Let  any  man  have  good  instruments  and  manage 
them  skilfully  on  proper  cases,  and  he  will  agree  to  the  truth  of  what  I 
state. 

The  operation,  like  everything  else  in  all  the  departments  of  human  life, 
is  imperfect.  It  cannot  cure  all.  But  it  has  relieved  many,  and  will  con- 
tinue to  do  so,  if  surgeons  will  use  it ;  it  has  been  the  prominent  cause  of 
relief  in  many  more,  and  will  be  so  hereafter,  if  men  will  theorize  less  and 
act  more.  It  has  been  the  sole  means  of  saving  life,  I  am  sure,  in  a  few 
of  my  cases ;  and  I  know  some  patients  have  died  within  the  last  few 
years,  in  New  England,  as  I  believe,  for  want  of  it,  under  the  care  of  others. 

It  is  certainly  innocuous,  and  gives  so  little  pain,  compared  with  the 
relief  that  it  affords,  that  patients  have  begged  for  it  to  be  repeated  again 
and  again,  as  a  mere  matter  of  relief.  In  my  opinion  it  ought  never  again 
to  be  allowed  to  fall  into  disuse  by  the  profession.  I  regard  any  man  who 
allows  a  patient  to  die  of  dyspnoea  from  pleuritic  effusion,  however  great 
may  be  the  complications  with  other  diseases  of  head,  chest,  or  abdomen, 
as  in  the  dilemma  of  him  who  is  either  wilfully  neglectful  of  some  of  the 
means  of  relief  or  cure,  now  by  experience  proved  to  be  always  at  hand,  or 
ignorant  of  the  simple  and  beautiful  operation  suggested  by  Dr.  Wyman. 
To  a  certain  extent  I  deem  my  connection  with  the  operation  somewhat 
providential.  I  had  seen,  in  the  earlier  years  of  my  practice,  men  die  with 
sudden  dyspnoea,  or,  after  months  of  obscure  disease,  die  with  one  pleural 
cavity  filled  with  serum,  and  not  a  particle  of  other  disease ;  and,  finally,  I 
have  seen  tubercular  phthisis  follow,  after  months  of  debility,  from  what 
was  simple  pleurisy  at  first. 

Having  no  surgical  tastes  myself,  shrinking  from  the  simplest  opera- 
tions, and  doing  nothing  of  the  kind  save  when  compelled  to  do  so,  I  at 
times  urged  surgeons  to  operate.  They  declined,  and  men  died.  Finally, 
in  cases  where  I  had  control,  I  took  the  responsibility,  and  asked  the  sur- 
geons to  do  the  manual  they  were  more  accustomed  to  than  I  was.  Their 
plan  was  incision  and  dissection  down  to  the  pleura,  and  a  suppurating 
wound  as  a  consequence,  a  long,  painful  operation.  At  last  Dr.  Wyman's 
instrument  and  method  came  to  my  notice.  I  seized  upon  them  as  those  I 
had  long  sought  for.  As  Dr.  Wyman  and  I  were  the  only  believers  in  the 
operation,  it  devolved  often  upon  me.  The  result  is  the  experience  which 
I  have  given  above.  And  now,  as  I  have  often  said,  I  would  as  readily 
puncture  the  chest  as  I  would  draw  a  tooth,  or  vaccinate  a  child. 

Boston,  Nov.  1862. 


22     Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  [Jan, 


Art.  II.  —  Conservative  Medicine  as  Applied  to  Therapeutics.  By 
Austin  Flint,  M.  D.,  Professor  of  the  Principles  and  Practice  of 
Medicine  in  the  Bellevue  Hospital  Medical  College,  and  in  the  Long 
Island  College  Hospital. 

An  explanation  of  the  term  Conservative  Medicine  may  be  required  for 
many  of  the  readers  of  this  journal.  The  term  should  be  at  once  explained, 
because  the  reader  may  suspect  a  meaning  quite  different  from  the  sense  in 
which  it  is  to  be  here  employed.  It  is  not  intended  by  this  term  to  refer 
to  a  conservatism  which  adheres  to  principles  and  rules  of  practice  on 
account  of  antiquity,  authority,  or  usage.  The  conservatism  meant  is  not 
an  adherence  to  doctrines  which  have  been  or  are  now  held.  It  is  not  that 
kind  of  conservatism  which  protests  against  any  changes,  and  resists  all 
innovations.  The  definition  of  the  term  will  be  found  to  involve  a  signifi- 
cation quite  the  reverse  of  all  this. 

In  an  essay  written  for  another  journal,1  the  writer  has  adopted  this 
term  as  an  analogue  of  the  term  Conservative  Surgery.  The  conservative 
surgeon,  before  resorting  to  capital  operations,  carefully  considers  the 
situation  of  patients,  and  the  danger  to  life  which  the  operations  involve ; 
and  he  regards  the  preservation  of  the  integrity  of  the  body  as  a  higher 
success  than  the  most  skilful  mutilation.  In  like  manner,  the  conservative 
physician  considers  fully  the  effects  of  the  potent  agencies  employed  as 
remedies,  appreciating  the  fact  that,  if  not  remedial,  these  agencies  are 
necessarily  injurious,  and  may  prove  destructive ;  and  in  the  management 
of  diseases  he  always  accords  due  importance  to  the  preservation  of  the 
powers  of  life.  As  the  true  surgeon  is  not  the  mere  operator,  unmindful 
of  the  duty  of  preserving  and  restoring  parts,  who  uses  the  knife  without 
regarding  the  condition  of  the  patient ;  so  the  true  physician  is  not  the 
routine  practitioner,  prescribing,  with  an  unsparing  hand,  active  thera- 
peutical measures  without  any  clear  apprehension  of  the  objects  to  be  ful- 
filled, making  no  allowance  for  the  natural  tendency  of  diseases  toward 
recovery,  and  disregarding  the  state  of  the  system. 

In  the  former  essay,  the  writer  attempted  to  show  that  the  grand  im- 
provements in  practical  medicine  which  have  been  steadily  going  on  for  the 
last  quarter  of  a  century,  are  characterized  by  conservatism  as  just  defined. 
This  conservatism  is  shown  by  a  greater  discrimination  in  the  use  of 
spoliative,  perturbatory,  and  debilitating  measures,  such  as  bloodletting, 

1  North  American  Medico-Chirurgical  Review  ;  the  concluding  No.,  viz. :  for  Nov. 
1861  (republished  in  the  American  Medical  Monthly,  No.  for  July,  1862).  In  the 
present  essay  the  writer  has  endeavoured  to  develop  the  subject  more  fully,  to 
present  additional  considerations,  and  to  treat  of  the  subject  under  different  points 
of  view. 


1863.]   Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  23 

mercurialization,  emetics,  cathartics,  and  severe  counter-irritation.  It  is 
shown  by  an  increased  use  of  remedies  which  are  potent  without  damaging 
the  organism,  such  as  opium  and  other  sedatives.  It  is  shown  by  a  reluc- 
tance to  interfere  actively  with  the  course  of  diseases  which  have  a  self- 
limited  career.  It  is  shown  by  a  greater  reliance  on  hygienic  measures. 
It  is  shown  by  more  attention  to  alimentation,  and  by  the  earlier  and  more 
efficient  employment  of  supporting  treatment  in  all  affections  which  tend 
to  destroy  life  by  asthenia.  The  term  conservative  medicine,  thus,  ex- 
presses the  great  characteristic  of  medical  practice  at  the  present  moment ; 
and  it  is  so,  not  from  the  authority  of  any  master  mind,  or  the  influence 
of  any  dominant  theory,  but  purely  because  it  is  incidental  to  the  advance- 
ment of  our  knowledge  of  pathological  conditions,  of  the  action  of  reme- 
dies, and  of  the  natural  history  of  diseases.  And  the  term  may  also  be 
considered  as  expressing  a  great  principle  which,  to  a  certain  extent,  should 
govern  the  views  and  conduct  of  the  physician.  Regarding  it  in  the 
latter  point  of  view,  I  shall  present  in  this  essay  some  considerations  con- 
nected with  the  application  of  the  principle  of  conservatism  to  therapeutics. 

Medicus  Naturae  minister  non  magister  est.  It  is  interesting  to  note 
the  principle  of  conservatism  as  manifested  by  nature  in  the  history  of  dis- 
eases. Waiving  all  questions  concerning  the  existence  and  sources  of  morbid 
conditions,  we  see  exemplifications  of  conservatism  on  every  side  in  patho- 
logical laws,  and  this  principle  becomes  more  and  more  conspicuous  in 
proportion  as  we  advance  in  our  knowledge  of  the  natural  history  of 
diseases.  The  well  established  fact  with  regard  to  many  diseases,  that 
they  tend  intrinsically  to  recovery,  and  not  to  death,  as  formerly  supposed, 
shows  the  conservatism  of  nature.  The  recovery,  sometimes  even  Without 
medication,  from  diseases  which  are  generally  destructive,  exemplifies  the 
principle.  This  is  certainly  true  of  pulmonary  tuberculosis.  The  prin- 
ciple is  exemplified  in  the  situation  of  the  great  majority  of  local  affections 
which  are  not  traumatic,  and  therefore  said  to  be  spontaneous ;  the  parts 
oftenest  affected  being  not  so  closely  connected  with  functions  necessary  to 
life  as  the  parts  which  generally  escape.  Thus,  the  great  majority  of  acute 
inflammations  are  seated  in  the  skin,  mucous  structures,  and  certain  of  the 
serous  membranes.  On  the  other  hand,  internal  organs,  the  functional 
exercise  of  which  is  more  immediately  concerned  in  vital  operations,  such  as 
the  stomach,  small  intestines,  pancreas,  liver,  kidneys,  are  comparatively  not 
often  acutely  inflamed.  The  principle  is  seen  in  the  spontaneous  removal 
of  morbid  products  from  different  parts  of  the  body,  and  in  the  disposal,  by 
elimination  or  otherwise,  of  the  materies  morbi  which  there  is  reason  to 
believe  give  rise  to  a  host  of  local  affections. 

The  study  of  the  events  belonging  to  the  natural  progress  of  individual 
diseases  discloses  abundant  illustrations  of  the  principle  of  conservatism. 
The  limitation  of  inflammation  to  a  particular  structure  furnishes  striking 
examples.    For  instance,  how  rare  is  it  that  the  inflammation  in  tonsillitis 


24     Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  [Jan. 

or  pharyngitis  extends  into  the  larynx !  Were  it  not  for  this  conservative 
provision,  how  serious  would  be  these  frequent  affections  of  the  throat  in 
view  of  the  liability  of  extensions  to  the  windpipe,  and  the  danger  attend- 
ant on  this  complication  !  Again,  what  a  vast  difference  is  there,  in  severity 
of  symptoms  and  danger  to  life,  between  ordinary  and  capillary  bronchitis  ; 
and  how  rare  the  latter,  notwithstanding  the  frequency  of  the  former  !  We 
can  only  explain  this  fact  by  stating  that  the  inflammation  extends  from 
the  larger  to  the  smaller  bronchial  tubes  only  as  an  exception  to  a  law  of 
the  disease.  The  physician,  by  attempting  to  place  himself  in  the  false 
position  of  the  master  of  nature,  may  thwart  her  conservative  provisions 
much  to  the  detriment  of  his  patients.  A  striking  illustration  of  this  fact 
is  afforded  by  the  practice  heretofore  inculcated  in  cases  of  hypertrophy  of 
the  heart.  We  have  been  taught  to  pursue  active  measures,  and,  by  some, 
measures  of  a  very  severe  character,  with  a  view  to  prevent  and  diminish 
hypertrophy  of  the  heart.  Now,  it  is  plain  that  this  form  of  enlargement 
is  a  most  important  conservative  provision  of  nature  to  obviate  evils  which 
would  otherwise  arise  from  the  valvular  lesions  which  precede  the  develop- 
ment of  cardiac  hypertrophy  in  the  vast  majority  of  cases.  The  physician 
is  the  servant  of  nature  when  he  does  not  interfere  with,  if,  indeed,  he  do 
not  endeavour  to  foster,  this  abnormal  condition. 

A  splendid  theme  for  an  essay  would  be  the  principle  of  conservatism  as 
exemplified  in  the  natural  history  of  diseases.  I  must  here  content  myself 
with  this  brief  reference  to  it. 

Directing  attention  to  conservative  medicine  as  applied  to  therapeutics, 
the  subject  naturally  presents  itself  in  a  twofold  aspect,  viz.  :  First,  as 
regards  the  therapeutical  indications  derived  from  our  knowledge  of  the 
pathological  character,  condition,  etc.,  of  diseases  ;  and,  Second,  as  regards 
the  general  object  of  remedial  measures.  I  shall  consider  the  subject  under 
these  two  heads  ;  but,  before  entering  upou  them,  there  are  certain  consider- 
ations which  are  suggested  by  the  inquiry,  What  are  some  of  the  general 
characteristics  of  conservative  medicine  ?  Or,  to  vary  the  question,  What 
are  the  more  prominent  of  the  traits  which  distinguish  the  conservative 
physician  ?  In  answer  to  this  question,  I  shall  offer  a  series  of  aphorisms 
which  will  lead  the  way  to  subsequent  inquiries  relating  to  therapeutical 
indications  and  objects. 

1.  The  conservative  physician  endeavours  to  protect  the  system,  on  the 
one  hand,  against  disease ;  and,  on  the  other  hand,  against  injurious  medi- 
cation. He  therefore  employs  potent  therapeutical  measures  only  with  a 
view  to  well  defined  objects  which  are  in  accordance  with  clear  indications. 
He  is  not  represented  by  the  allegory  of  the  blind  man  with  the  club ; 
he  never  strikes  at  random,  but  always  with  a  purpose  and  aim.  He 
regards  active  remedial  agencies  as,  in  themselves,  evils  which  become 
blessings  when  they  aid  in  the  escape  from  other  and  greater  evils.  To 


1863.]   Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  25 

quote  the  language  which  some  one  has  used,  "he  is  content  with  doing 
nothing  when  ignorant  how  to  do  good." 

2.  The  conservative  physician  does  not  undertake  to  control  diseases 
which,  with  our  existing  knowledge,  are  uncontrollable.  And  if  he  employ 
measures  for  that  end  tentatively,  he  is  governed  by  this  rule,  viz.,  not  to 
subject  the  patient  to  measures  which,  if  they  do  not  prove  successful,  will 
diminish  materially  the  chances  of  his  passing  through  the  disease  with 
safety. 

3.  In  the  management  of  all  the  diseases  which  our  existing  knowledge 
does  not  enable  him  to  control,  the  conservative  physician  always  pursues 
the  expectant  practice,  using  this  term  in  its  proper  sense,  viz.,  as  denoting 
not  necessarily  the  attitude  of  a  passive  spectator  of  the  progress  of  dis- 
ease, but  the  adaptation  of  therapeutical  measures  to  circumstances  as  they 
arise.  In  this  sense,  expectation  expresses  the  proper  conduct  of  the  prac- 
titioner whenever  he  is  not  warranted  in  resorting  to  treatment  with  a  view 
to  arresting  the  progress  of  disease  or  abridging  its  duration. 

4.  The  practice  of  the  conservative  physician  has  reference  always,  not 
alone  to  the  disease,  but  to  the  condition  of  the  patient.  In  the  language 
of  Chomel,  he  does  not  treat  diseases,  but  he  treats  patients  affected  with 
diseases.  A  formularied,  routine  method  of  treatment  for  any  disease  is, 
therefore,  with  him  impossible.  In  different  cases  of  the  same  disease  his 
therapeutical  measures  may  be  quite  different,  and  even  directly  opposite  in 
their  character  and  effects.  Of  two  persons  attacked  with  a  disease,  for 
instance  pneumonia,  one  may  seem  to  him  to  claim  measures  which  are 
commonly  known  as  antiphlogistic,  while  the  other  may  appear  to  require 
tonics  and  stimulants. 

5.  The  conservative  physician  directs  his  attention  with  special  care  to 
the  vital  powers.  He  is  always  ready  to  support  these  wherever  he  sees 
evidence  of  their  failure,  without  regard  to  the  name  or  the  stage  of  the 
disease.  He  does  not  wait  for  the  last  flickerings  of  the  lamp  of  life  before 
resorting  to  sustaining  measures  ;  he  endeavours  to  prevent  the  flame  from 
falling  to  so  low  an  ebb,  and  with  sagacious  foresight  he  would  forestall 
the  occurrence  of  failure,  resorting  to  sustaining  measures  even  when  not 
imperatively  required,  rather  than  run  much  risk  of  deferring  them  when 
they  might  be  useful.  A  full  appreciation  of  the  importance  of  supporting 
the  powers  of  life  (using  this  metaphorical  expression  in  its  common,  well 
understood,  practical  sense)  is,  par  excellence,  a  trait  of  conservative 
medicine. 

6.  The  conservative  physician  is  by  no  means  a  timid  practitioner.  He 
carries  a  lancet,  and  is  ready  to  use  it  under  certain  circumstances,  although, 
it  must  be  confessed,  the  instrument  is  apt  to  become  rusty  from  non-use. 
He  does  not  repudiate  any  of  the  potent  measures  embraced  in  the  materia 
medica,  but  he  seeks  to  employ  them  with  a  nice  discrimination.  He  is 
bold  in  the  use  of  certain  remedies  which  are  used  with  timidity  by  many 


26     Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  [Jan. 

practitioners  to  whom  the  term  conservative  is  not  applicable,  viz.,  such 
remedies  as  quinia,  opium,  and  alcoholics.  His  boldness,  however,  is  quite 
as  much  displayed  by  resolutely  forbearing  to  resort  to  potent  measures 
whenever  active  interference  does  not  seem  to  him  to  be  called  for,  as  it  is 
by  the  employment  of  powerful  therapeutical  agencies. 

*7.  Recognizing  the  fact  that  medicine  should  be  progressive ;  that  new 
developments  in  physiology  and  pathology,  together  with  the  accumulating 
fruits  of  experience,  should  lead  to  constant  improvement  in  the  ars  me- 
dendi,  the  conservative  physician  repudiates  all  dogmas  or  systems  of  prac- 
tice, whether  without  or  within  the  pale  of  the  profession,  which  shackle 
the  mind  and  stand  in  the  way  of  progress.  In  medical  faith  he  is  inde- 
pendent of  creeds  and  discipleship.  He  occupies  a  middle  ground  with 
regard  to  the  extremes  of  the  present  day  as  represented  by  old  fogyism 
and  young  physic. 

8.  The  most  distinguishing  characters  of  conservative  medicine,  in  a  few 
words,  are  as  follows:  Recognizing  as  a  fundamental  principle  of  thera- 
peutics that  potent  remedies  are  never  neutral,  but  must  do  either  good  or 
harm  in  proportion  to  their  potency,  it  aims  to  abstain  from  active  mea- 
sures if  uncalled  for  or  of  doubtful  utility,  and  it  strives  to  assist  the  pow- 
ers of  life,  by  means  of  remedial  and  hygienic  influences,  in  enduring  and 
triumphing  over  disease. 

This  enumeration  of  some  of  the  prominent  traits  of  conservative  medi- 
cine might  be  extended,  and  each  might  serve  as  a  text  for  a  distinct  essay. 
But  I  proceed  to  consider  the  subject  under  the  first  head,  viz.,  "as  regards 
the  therapeutical  indications  derived  from  our  knowledge  of  the  pathologi- 
cal character,  causation,  etc.,  of  diseases."  And  it  will  serve  our  present 
purpose  to  arrange  diseases  into  the  following  classes :  Inflammatory  affec- 
tions, the  essential  fevers,  degenerations  of  structure,  functional  disorders, 
and  a  residual  class  to  which  we  may  apply  the  term  diathetic.  The  sub- 
ject covers  so  wide  a  field  that  it  is  hardly  necessary  to  disclaim  the  attempt 
to  consider  it  fully  within  the  limits  of  a  few  pages.  The  considerations 
presented  in  this  essay  must  needs  be  fragmentary  and  discursive,  the  object 
being  merely  to  suggest  trains  of  reflection. 

Inflammations  form  the  larger  share  of  the  affections  with  which  the 
physician,  as  well  as  the  surgeon,  has  to  deal.  The  morbid  processes  em- 
braced under  the  name  of  inflammation  have  accordingly  been  studied  with 
great  interest;  and  with  what  success?  The  series  of  phenomena  which 
make  up  the  history  of  inflammation  have  been  unfolded  from  the  first 
appreciable  event,  viz.,  the  determination  of  blood  to,  and  its  detention  in, 
the  inflamed  part,  to  the  various  terminations  of  the  inflammatory  processes. 
But  the  essential  pathology  underlies  that  first  appreciable  event.  What 
is  it  which  occasions  the  attraction  of  blood  to,  and  its  detention  in,  an 
inflamed  part?    The  causation  involves  a  knowledge  of  inappreciable  con- 


1863.]   Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  21 

ditions  antecedent  to  the  development  of  the  phenomena  of  inflammation. 
Reference  is  here  had,  of  course,  to  inflammations  which  are  not  traumatic. 
It  is  as  certain  that  some  unknown  causative  influence  exists  and  acts  in, 
as  yet,  some  unknown  manner,  to  give  rise  to  an  inflammation  when  it  is 
said  to  be  spontaneous,  as  it  is  that  the  local  injury  produces  the  inflam- 
mation when  traumatic.  If  this  be  a  fair  statement  of  our  knowledge  of 
the  essential  pathology  and  causation  of  inflammation,  what  rational  con- 
clusion may  be  drawn  therefrom  respecting  therapeutics  ?  Ought  we  to 
expect  to  be  able  to  suppress  an  inflammation  by  diminishing  the  quantity 
of  blood  in  the  body;  or  by  trying  to  direct  blood  elsewhere;  or  by  the 
production  of  an  inflammation  in  another  part;  or  by  evacuating  the  sto- 
mach and  bowels ;  or  by  exciting  some  violent  commotion  in  the  system 
under  a  vague  notion  that  the  local  affection  may  be  shaken  off?  Are  the 
pathological  and  causative  conditions  seated  in  the  blood  or  in  the  nervous 
system,  or  in  both  ?  This  question  we  may  hope  to  answer  when  the  phy- 
siologist has  explained  more  fully  the  mysteries  of  the  capillary  circulation 
and  of  nutrition.  Until  then,  we  can  hardly  expect  to  find  rational  indi- 
cations for  arresting  inflammation.  Our  knowledge  of  the  means  for  this 
end  must  be  empirical;  and  experience  has  not  yet  led  to  the  discovery. 

Let  it  not  be  said  that  medicine  is  disparaged  by  this  view  of  the  re- 
sources of  our  art.  A  conservative  practice  can  do  vastly  more  than  simply 
not  do  harm  by  vainly  attempting,  with  the  measures  just  named,  to  extin- 
guish inflammations.  It  can  do  much  for  the  safety  of  the  parts  inflamed 
by  measures  to  palliate  local  symptoms,  to  promote  favorable  modes  of  ter- 
mination, to  obviate  incidental  evils,  to  aid  in  the  removal  of  morbid  pro- 
ducts, etc.  Conservatism  dictates  measures  for  those  ends,  embracing 
surgical  as  well  as  medical  interference,  as,  for  example,  when  paracentesis 
is  resorted  to  in  pleurisy.  Conservative  practice  can  do  a  vast  deal  by 
measures  addressed  to  the  system.  To  obviate  the  general  disturbance 
occasioned  by  inflammations,  or,  in  other  words,  to  render  the  system  more 
tolerant  of  their  existence,  by  means  of  opium  and  other  anodyne  remedies; 
to  support  the  vital  powers  by  means  of  tonics,  alcoholics,  and  nutriment — 
these  are  indications  which  have  reference  to  the  safety  of  the  patient,  and 
a  speedy  triumph  over  the  disease.  In  fulfilling  these  indications  the  con- 
servative physician  is  often  called  upon  to  act  boldly,  resolutely,  and  per- 
severingly. 

It  is  to  be  considered  that,  exclusive  of  certain  acute  inflammations  which 
may  destroy  life  by  obstructing  the  exercise  of  vital  functions,  as  pericar- 
ditis by  the  pressure  of  liquid  effusion,  laryngitis  and  capillary  bronchitis, 
by  preventing  the  passage  of  air  to  and  from  the  pulmonary  vesicles,  etc., 
death  is  generally  caused,  not  by  an  irremediable  injury  to  the  inflamed 
part,  but  by  the  general  disorder  and  failure  of  the  vital  powers.  Acute 
peritonitis,  for  example,  is  a  dangerous  disease,  not  on  account  of  the 
damage  done  to  the  peritoneum  or  the  abdominal  viscera,  but  because  the 


28     Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  [Jan. 

powers  of  life  do  not  hold  out  a  sufficient  time  for  recovery.  Patients  may 
die  with  this,  as  with  other  inflammatory  affections,  for  the  simple  reason 
that  they  do  not  live  long  enough  for  the  restorative  processes  to  take 
place.  Is  it  not,  then,  an  indication  not  less  in  accordance  with  conserva- 
tism than  with  common  sense,  to  endeavour  to  obviate  the  general  disorder, 
prevent  failure  of  the  vital  powers,  and  prolong  life  sufficiently  for  restora- 
tion ? 

Acute  peritonitis  has  just  been  cited.  How  striking  an  example  does 
this  disease  afford  of  an  immense  improvement  due  to  bold  conservative 
practice !  How  fatal  was  this  disease  under  the  treatment  until  recently  in 
vogue,  and  for  which,  alas !  the  practitioner  still  finds  authority  in  some 
standard  works !  Who  that  has  had  an  opportunity  of  contrasting  the 
past  and  present  methods  of  treatment,  can  doubt  that  the  former  want  of 
success  was  measurably  due  to  over  depletion  and  cathartics  ?  The  com- 
parative success  of  the  present  treatment,  doubtless,  is  by  no  means  wholly 
due  to  the  abandonment  of  these  measures.  The  free  use  of  opium,  and 
of  alcoholics  when  indicated,  has  contributed,  in  no  small  measure,  to  this 
success.  This  is  a  reasonable  opinion,  although  here,  as  with  respect  to 
other  diseases  which  have  rarely  been  observed  under  circumstances  in  which 
no  medical  treatment  was  employed,  it  is  not  easy  to  determine  how  much 
a  more  successful  treatment  may  depend  simply  on  the  displacement  of 
injurious  measures. 

Directing  attention  to  chronic  inflammations,  to  what  is  their  chronicity 
attributable?  Sometimes  to  an  obvious,  persisting  cause  of  irritation; 
sometimes  to  a  palpable,  associated  morbid  condition,  as  when  bronchitis 
is  kept  up  by  pulmonary  congestion  due  to  cardiac  lesions ;  sometimes  to 
lesions  which,  from  the  situation  of  the  part  affected,  are  restored  with 
difficulty,  as  in  cases  of  chronic  dysentery.  In  other  instances  it  is  attri- 
butable to  an  inappreciable  condition  which,  for  the  sake  of  distinction,  it 
is  customary  to  call  a  constitutional  cause.  Who  has  not  seen  chronic 
venereal  ulcers  of  long  standing  heal  under  the  use  of  mercury;  or  peri- 
ostitis, from  which  the  patient  may  have  suffered  for  many  months,  rapidly 
disappear  under  the  use  of  the  iodide  of  potassium  ?  Now,  there  is  reason 
to  believe  that  certain  chronic  inflammations  are  not  less  dependent  on  a 
constitutional  causation,  although  the  cause  may  not  be  of  a  specific  cha- 
racter like  that  in  syphilis.  This  is  by  no  means  a  new  idea.  It  was  the 
leading  idea  in  the  teachings  of  Abernethy,  and,  as  the  basis  of  the  so- 
called  alterative  treatment,  of  which  mercury  was  considered  as  the  chief, 
it  has  led  to  not  a  little  injurious  medication.  In  fact,  a  signal  instance 
of  conservatism  is  the  infrequent  induction  of  mercurialization  in  the  treat- 
ment of  chronic  inflammations,  at  the  present  time,  as  contrasted  with  the 
frequent  resort  to  this  measure  but  a  few  years  ago.  On  the  other  hand, 
the  existence  of  a  constitutional  causative  condition  in  certain  inflamma- 
tions is  often  not  sufficiently  considered  by  practitioners,  and  hence  an  over- 


1863.]  Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  29 

reliance  on  topical  measures  of  treatment  which  are  not  only  inefficacious, 
but  not  infrequently  contribute  to  perpetuate  the  affection. 

As  an  illustration  of  the  fact  just  stated,  I  will  select  an  affection  which 
of  late  years  has  attracted  a  good  deal  of  attention,  both  professional  and 
popular,  viz.,  chronic  pharyngitis.  Exclusive  of  cases  of  syphilis,  this 
affection  is  very  common,  especially  among  persons  of  the  male  sex  engaged 
in  pursuits  which  overtask  the  nervous  system  and  involve  sedentary  habits. 
For  several  years  past  this  affection  has  been  treated  very  generally  by 
means  of  topical,  cauterizing  applications,  usually  the  nitrate  of  silver, 
repeated  at  intervals  for  a  greater  or  less  period.  Has  this  treatment 
proved  successful  ?  For  one,  after  considerable  experience,  I  am  prepared 
to  answer  this  question  in  the  negative,  and  this  I  find  to  be  a  conclusion 
drawn  by  many  from  the  results  of  experimental  observation.  The  treat- 
ment, I  am  persuaded,  is  not  only  rarely  beneficial,  but  often  aggravates 
the  affection.  The  affection  is  the  local  expression  of  a  constitutional 
state,  and  will  prove  rebellious  to  treatment  so  long  as  the  latter  continues. 
General  measures,  in  which  hygiene  plays  an  important  part,  effects  the 
cure.  I  shall  content  myself  with  this  illustration,  although  others  might 
be  added.  Suffice  it  to  say  that  the  same  conclusions,  I  am  persuaded,  may 
be  drawn  with  respect  to  severe  topical  treatment  in  diphtheria,  and  in 
chronic  inflammations  seated  in  other  accessible  situations,  for  example, 
ophthalmias,  erysipelas,  and  certain  of  the  affections  of  the  cervix  uteri. 

Conservatism  dictates  an  appreciation  of  the  dependence  of  local  affec- 
tions on  a  morbid  constitutional  state,  although  our  present  knowledge  may  , 
not  enable  us  to  understand  the  primary  and  essential  deviations  from  health 
which  constitute  this  state.  Conservatism  sanctions  the  trial  of  remedies, 
under  proper  restrictions,  with  a  view  to  the  removal  of  this  state.  Con- 
servatism is  ready  to  accept  remedies  for  that  end,  the  efficacy  of  which  has 
been  empirically  established,  without  requiring  an  explanation  of  their 
modus  operandi.  The  chlorate  of  potassa,  in  certain  affections  of  the 
mucous  membranes,  would  appear  to  be  a  remedy  of  this  description.  We 
may  hope  that  additional  remedies  of  this  kind  may,  from  time  to  time,  be 
discovered.  In  the  mean  while,  conservatism  enjoins,  not  only  an  acquaint- 
ance with  the  resources  of  our  art,  but  a  just  appreciation  of  the  limitations' 
incident  to  the  present  state  of  knowledge;  and  hence,  with  reference  to 
the  affections  under  consideration,  conservatism  tries  to  avoid  being  led  into 
injurious  medication  by  such  loose  expressions  as  "substitution  of  healthy 
for  diseased  action,"  and  "alterative  treatment,"  expressions  which  have 
served  as  a  warrant  for  not  a  little  mischievous  practice. 

Finally,  conservatism  recognizes  as  a  general  indication  in  chronic  inflam- 
mations, to  place  and  maintain  the  body  in  the  best  possible  condition,  by 
means  of  tonic  remedies,  adequate  alimentation,  and  the  hygienic  influences 
which  conduce  to  that  end.  It  is  consistent  alike  with  experience  and  good 
sense,  that,  other  things  being  equal,  the  nearer  the  normal  standard  the 


30     Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  [Jan. 

condition  commonly  known  as  the  general  health,  the  better  the  prospect 
of  recovery  from  chronic  inflammation,  and  the  better  fortified  is  the  system 
to  endure  its  continuance. 

Passing  to  the  essential  fevers,  we  know  that  each  of  them  has  its  own 
conservative,  morbific  agent,  that  is,  a  special  cause  which  will  produce  one 
particular  species  of  fever,  and  that  species  only.  The  special  cause  of 
variola,  for  example,  will  never  give  rise  to  rubeola  or  scarlatina.  The 
special  cause  known  as  marsh  miasm  will  not  give  rise  to  typhoid  or  typhus 
fever.  Each  of  the  two  last  named  species  of  fever  has  its  own  special 
cause  which  will  not  give  rise  to  the  other  species.  These  statements  are 
based  on  logical  inferences  from  certain  facts,  not  on  the  demonstrative 
proof  afforded  by  an  analysis  and  comparison  of  the  different  agents  which 
constitute  the  poisons  producing  these  diseases.  Our  belief  in  the  existence 
of  these  poisons  is  not  derived  from  our  knowledge  of  their  nature.  What 
are  their  chemical  and  physical  characters  we  know  not.  We  know  that  an 
exceedingly  small  and  even  an  inappreciable  amount  suffices  to  produce  fever, 
as  when  certain  of  these  fevers  are  produced  by  inoculation  and  by  con- 
tagion ;  and  analogical  reasoning  leads  us  to  the  conclusion  that  they  act 
as  ferments,  or  on  the  very  imperfectly  understood  principle  of  catalysis. 
Hence,  we  say  these  diseases  belong  to  a  class  distinguished  as  zymotic. 
And  if  they  act  on  the  principle  of  catalysis,  their  primary  action  must  be 
in  the  blood.  We,  therefore,  accept  the  humoral  pathology  of  fever.  The 
demonstrative  part  of  this  pathology  is  confessedly  wanting,  but  it  may  be 
considered  logically  established. 

Now,  the  aim  of  conservative  medicine  being  to  afford  protection  against 
disease,  on  the  one  hand,  and,  on  the  other  hand,  against  needless  and 
therefore  injurious  medication,  the  first  inquiry  is,  Do  the  present  resources 
of  our  art  enable  us  to  control  these  diseases  ?  As  regards  the  purely 
periodical  fevers,  this  question  may  be  answered  affirmatively.  We  can 
control  these  by  means  of  certain  special  or  specific  remedies  of  which 
quinia  is  the  most  efficient.  These  remedies,  for  the  time  being,  either 
neutralize  the  poison,  or,  in  some  way,  suspend  its  morbific  action.  Con- 
servatism thus  manifests  its  power  to  protect  against  disease  by  its  ability 
to  arrest  these  fevers.  And  it  has  also  manifested  its  protection  against 
needless  medication  by  doing  away  with  certain  preparatory  and  adjunctive 
measures  which,  until  recently,  were  deemed  important,  experience  having 
abundantly  shown  their  inutility.  In  fact,  the  doing  away  with  bleeding, 
emetics,  cathartics,  and  mercurialization,  in  the  treatment  of  intermitting 
and  remitting  fever,  is  a  striking  illustration  of  conservatism.  It  is  but  a 
few  years  ago  that  these  measures  were  in  vogue ;  it  was  then  thought  to 
be  injudicious  to  enter  upon  the  special  remedy  at  once;  this  remedy  was 
given  timidly  in  small  doses  only,  never  except  in  the  apyrexial  period,  and 
not  if  the  fever  were  complicated  with  local  inflammation.  In  each  of  these 


1863.]   Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  31 


particulars,  the  treatment  has  changed,  and  the  change  constitutes  one  of 
the  most  important  of  the  late  improvements  in  practical  medicine.1 

Protection  against  the  eruptive  and  continued  fevers,  like  that  afforded 
by  quinia  and  other  anti-periodic  remedies  against  the  periodical  fevers,  is 
reserved  for  the  future.  We  cannot  control  the  former  as  we  can  the  lat- 
ter. Yet,  with  regard  to  the  most  formidable  of  all,  in  smallpox,  the 
glorious  discovery  of  the  immortal  Jenner,  by  way  of  prevention  and  modi- 
fication of  its  severity,  affords  a  protection  almost  complete,  and  has 
deprived  the  disease  of  nearly  all  its  terrors.  The  contagiousness  of  the 
eruptive  and  continued  fevers,  and  the  fact  that  they  have  a  definite,  self- 
limited  career,  may  seem  to  discourage  an  expectation  that  means  of  con- 
trolling them  will  ever  be  discovered ;  but  how  little  ground  was  there  to 
anticipate  the  fact  that  the  virus  of  variola,  as  modified  by  its  production 
in  the  body  of  the  cow,  would  give  rise  to  an  affection  insignificant  except 
in  regard  of  its  power  of  protecting  against  the  virus  received  from  our 
own  species  ?  How  many  would  have  anticipated  the  wonderful  modifica- 
tion of  smallpox  produced  by  inoculation  !  It  is  not  unreasonable  to 
hope  that  other  Jenners  will  hereafter  arise,  although  Providence  may  have 
ordained  their  appearance  at  remote  epochs.  Meanwhile,  it  is  a  legitimate 
object  of  experimental  research  to  discover  means  of  preventing,  arresting, 
and  modifying  the  eruptive  and  continued  fevers.  There  is  ground  for  the 
belief  that  certain  measures,  which  have  been  already  tried,  are  occasionally 
successful  in  suspending  and  shortening  typhus  and  typhoid  fever.  This 
remark  has  reference  to  large  doses  of  opium,  and  the  wet  sheet.  But  in 
experiments  for  these  ends  the  rule  of  conservatism  already  mentioned  is  to 
be  observed,  viz :  not  to  make  trial  of  measures  which,  if  they  do  not  suc- 
ceed, will  be  likely  to  prove  in  themselves  dangerous.  The  conservatism 
of  present  practice  is  strikingly  shown  by  the  relinquishment  of  potent 
measures  to  break  up  the  continued  fevers,  viz.,  bleeding,  emetics,  cathartics, 
and  mercurialization,  the  inefficacy  of  which  experience  has  abundantly 
established. 

The  present  prevailing  views  of  the  management  of  the  eruptive  and 

1  The  January  No.  of  this  Journal,  in  1841,  contains  an  article,  by  the  author 
of  this  essay,  on  the  management  of  intermitting  fever.  In  that  article  the  follow- 
ing points  were  set  forth:  The  safety  and  propriety  of  giving  quinia  in  large  doses, 
i.  e.,  from  ten  to  twenty  grains  ;  the  inutility  of  preparatory  treatment,  and  of  the 
use  of  emetics,  cathartics,  etc.,  during  the  progress  of  the  disease  ;  the  diminished 
liability  to  relapses  in  proportion  as  the  paroxysms  are  promptly  interrupted,  and, 
in  cases  in  which  inflammatory  complications  exist,  the  importance  of  giving  the 
special  remedy  in  doses  sufficient  to  arrest  at  once  the  paroxysms.  Those  views 
were  then  at  variance  with  the  prevailing  modes  of  practice.  The  writer  is  very 
far  from  assuming  to  have  exerted  much  agency  in  producing  the  change  in  prac- 
tice; but  he  trusts  he  may  be  excused  for  stating  that  the  article  referred  to 
advocated,  in  all  respects,  the  change  which  has  actually  taken  place. 


32     Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  [Jan. 


continued  fevers,  irrespective  of  measures  to  arrest  them,  or  abridge  their 
duration,  are  eminently  on  the  side  of  that  conservatism  which  protects  the 
system  against  needless  medication.  Practitioners  now  rarely  subject 
patients  to  loss  of  blood  in  order  to  abate  the  intensity  of  febrile  excite- 
ment and  prevent  the  development  of  local  congestions  or  inflammations  ; 
they  do  not  produce  local  complications  by  blisters  and  other  means  of 
counter-irritation ;  they  do  not  subject  the  system  to  the  perturbation  of 
cathartics  to  change  the  condition  of  the  stomach  and  remove  saburral 
matters  ;  they  do  not  give  cathartic  remedies  to  cleanse  the  bowels,  increase 
the  flow  of  bile,  or  improve  the  secretions  ;  they  do  not  resort  to  powerful 
measures  to  produce  perspirations  which  they  hope  may  prove  critical ; 
they  do  not  attempt  to  salivate  under  the  vague  notion  of  producing  an 
alterative  effect.  These  anti-conservative  measures  belong  to  the  past,  and 
the  physician  is  now  satisfied,  if  he  cannot  arrest  or  abridge  these  diseases, 
to  pursue  an  expectant  course ;  he  watches  symptoms,  and  meets  indica- 
tions as  they  arise  in  individual  cases.  He  may  see  nothing  which  calls 
for  medication  during  the  progress  of  the  disease.  Hygienic  conditions 
receive  his  special  attention,  the  importance  of  these  having  come  to  be  more 
and  more  appreciated  in  proportion  as  remedial  agencies  have  been  used 
with  greater  discrimination.  Palliation  of  symptoms  and  supporting  mea- 
sures often  constitute  the  sum  and  substance  of  his  treatment.  The  latter, 
if  occasion  require,  he  employs  boldly  and  perseveringly.  In  certain  cases, 
when  his  great  object  is  "to  obviate  the  tendency  to  death,"  he  supports 
his  patient  as  he  would  hold  up  a  drowning  man,  until,  by  vigorous  exer- 
tions, at  length  the  shore  is  reached. 

No  branch  of  the  science  of  medicine  has  excited  greater  interest,  of  late 
years,  than  the  study  of  structural  changes.  Here  the  application  of  the 
microscope  has  been  of  inestimable  service,  by  unfolding,  first,  the  minute 
structure  of  organs  in  health,  and,  second,  the  alterations  due  to  disease. 
How  much  light  has  been  shed  on  our  knowledge  of  the  various  lesions  of 
different  organs — the  brain,  liver,  kidneys,  heart,  etc. !  And  much  more 
information  is  to  be  expected  from  continued  microscopical  researches. 
But,  complete  as  our  knowledge  of  appreciable  changes  of  structure  may 
become,  this  knowledge  is  but  the  scaffolding  raising  us  higher  and  higher 
toward  the  primary  conditions  of  disease ;  and  these  are  still  beyond  us 
when  we  have  reached  the  highest  point  of  elevation.  In  other  words, 
structural  changes  are  the  effects  of  prior  morbid  actions,  and  the  latter 
must  be  understood  before  we  can  comprehend  fully  the  essential  character 
of  diseases.  I  am  far  from  wishing  by  this  statement  to  depreciate  the 
results  of  microscopical  researches.  It  is  easy  to  cite  illustrations  of  their 
great  practical  value.  Thus,  our  knowledge  of  the  changes  which  the 
cerebral  arteries  undergo  from  the  deposit  of  fatty  granules,  enables  us  to 
explain  the  occurrence  of  apoplexy ;  our  knowledge  of  the  fatty  degenera- 


✓ 


1863.]   Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  33 

tion  of  the  muscular  fibres  of  the  heart,  affords  an  explanation  of  the 
weakness  of  that  organ  in  certain  cases  and  the  occasional  rupture  of  its 
walls ;  the  presence  of  newly  developed  fibrous  tissue  in  the  interlobular 
spaces  of  the  liver  in  cirrhosis,  renders  the  occurrence  of  ascites  intelligible  ; 
the  loss  of  the  secretory  cells  of  the  convoluted  tubes  of  the  kidneys  in 
certain  affections  of  the  kidneys,  accounts  for  the  production  of  uraemia — 
and  numerous  additional  examples  might  be  cited  to  show  how  important 
in  their  bearings  on  practical  medicine  are  the  developments  for  which  we 
are  indebted  to  the  microscope.  Still,  morbid  anatomy,  in  its  widest  scope, 
is  only  but  a  province  of  the  natural  history  of  diseases.  It  describes  ap- 
pearances ;  it  traces  the  different  steps  of  morbid  alterations,  and  strives  to 
ascertain  their  points  of  departure — and  this  is  vastly  important ;  but  the 
prime  source  of  the  lesions  which  it  studies  underlies  and  precedes  the 
earliest  of  the  changes  which  the  senses  can  discover.  Take,  for  example, 
Bright's  disease,  and  admit  the  researches  of  Dr.  George  Johnson  and 
others  to  have  established  that  the  structural  changes  incidental  to  this 
disease  have  their  point  of  departure  in  the  secretory  cells  of  the  kidneys, 
and  that  the  various  morbid  changes  of  the  organs  are  fully  explained  by 
the  loss  of  cells,  the  presence  of  fatty  and  other  deposits,  etc.,  we  do  not 
reach  the  fons  et  origo  of  the  disease.  The  morbid  conditions  on  which 
hangs  the  first  link  of  the  chain  of  appreciable  alterations,  is  inappreciable 
and,  as  yet,  unknown. 

Commensurate  with  our  progress  in  the  knowledge  of  structural  changes, 
has  been  improvement  in  the  means  of  determining  their  existence  during 
life.  We  have  learned  to  investigate  certain  vital  organs  with  wonderful 
accuracy.  The  examination  of  the  urine,  chemically  and  microscopically, 
reveals  morbid  conditions  of  the  kidneys ;  auscultation,  together  with  the 
other  methods  of  physical  examination  of  the  chest,  discloses  the  lesions 
to  which  the  lungs  and  heart  are  liable.  Means  of  interrogating,  in  like 
manner,  the  liver  and  other  of  the  abdominal  viscera,  will,  in  all  proba- 
bility, be  found  when  the  preceding  changes  and  their  pathological  relations 
have  been  more  fully  studied.  But  it  is  to  be  considered  that  the  diagnostician 
deals  with  symptoms  and  signs  representing  existing  changes  which  have 
made  more  or  less  progress.  He  determines  mischief  already  done.  He  has 
not  often  the  opportunity,  and,  if  he  had,  he  is  rarely  able  to  foresee  the 
occurrence  of  internal  lesions.  Every  clinical  observer  knows  that  affections 
involving  irremediable  lesions  are  developed  imperceptibly,  and  are  already 
developed  when  cases  first  come  under  the  cognizance  of  the  physician. 
This  is  true  of  Bright's  disease,  cirrhosis  of  the  liver,  pulmonary  tubercu- 
losis, carcinoma  in  various  situations,  organic  disease  of  heart,  etc.  Im- 
mensely important  as  it  is  to  determine  the  existence  of  lesions  and  the 
amount  of  damage  which  they  have  occasioned,  it  would  be  of  immense 
advantage  to  be  able  to  go  still  farther  and  ascertain  the  existence  of  those 
No.  LXXXIX.— Jan.  1863.  3 


34     Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  [Jan. 

morbid  actions  which  precede  and  determine  the  development  of  structural 
changes. 

Not  to  dwell  too  long  on  these  considerations,  let  us  inquire  into  their 
general  bearings  on  therapeutical  indications.  What  are  the  dictates  of 
conservatism  in  view  of  the  foregoing  facts  ?  Suppose  an  important  organ 
to  be  the  seat  of  some  structural  change,  and,  so  far  as  the  organ  is  already 
damaged  by  the  change,  the  affection  to  be  irremediable.  Nature,  to  a 
certain  extent,  has  provided  for  such  a  state  of  things,  by  furnishing  a 
surplus  amount  of  structure  in  important  organs.  The  lungs  are  so  far 
beyond  the  actual  wants  of  the  economy,  that  a  loss  equivalent  to  the 
functional  capability  of  one  whole  lung  is  not  incompatible  with  robust 
health.  The  two  kidneys  exceed  by  at  least  the  function  of  one  of  these 
organs,  the  necessities  of  the  system.  The  heart  may  be  considerably  im- 
paired, and  still  be  sufficient  for  the  circulation  ;  and  so  with  the  liver,  and, 
doubtless,  the  glandular  organs  contained  in  the  stomach  and  intestines. 
Medicus  naturae  minister  est.  The  physician  should  endeavour  to  aid 
nature  in  doing  as  well  as  possible  under  the  damage  which  the  affected 
organ  has  sustained.  How  is  this  object  to  be  attained  ?  In  general 
terms,  by  preventing,  if  possible,  any  farther  progress  of  the  structural 
change,  and  placing  the  organism  in  the  best  possible  condition  compatible 
with  the  existence  of  the  lesion. 

We  may  lay  it  down  as  a  rule  of  general  application,  that  an  organic 
affection  is  less  liable  to  progress,  the  functions  of  the  affected  organ  suffer 
less,  the  system  is  less  disturbed,  and  the  local  mischief  is  borne  for  a  longer 
period,  in  proportion  as,  in  all  other  respects,  the  body  approximates  to  a 
state  of  health.  Striking  results  are  often  obtained  in  cases  of  an  incurable 
malady,  by  effecting  an  improvement  in  the  state  of  the  system.  For  ex- 
ample, it  has  occurred  to  me  repeatedly  to  see  patients  enter  hospitals 
with  Bright's  disease  accompanied  with  such  an  amount  of  dropsy,  pros- 
tration, etc.,  that  the  prospect  of  improvement  seemed  most  unfavourable  ; ' 
but,  after  a  time,  the  dropsy  has  disappeared,  the  strength  has  improved, 
and  the  patients  have  left  the  hospital  feeling  able  to  return  to  labour.  I 
do  not  now  refer  to  cases  of  acute  albuminuria,  which  may  pursue  this 
course  and  end  in  recovery,  but  to  chronic  cases  of  an  incurable  affection 
of  the  kidney.  The  lesion  continues  in  the  cases  referred  to,  the  urine 
remains  albuminous,  and,  sooner  or  later,  grave  consequences  are  developed. 
Whence  the  marked  improvement  and  apparent  recovery  ?  Simply  because 
the  system  has  been  improved  by  rest,  by  nutritious  food,  by  tonic  remedies, 
and,  probably,  by  an  interruption  of  habits  which  have  contributed  greatly 
to  the  production  of  the  local  affection.  Similar  examples  might  be  cited 
of  patients  with  other  affections,  such  as  cirrhosis  of  the  liver,  cardiac 
lesions,  and  pulmonary  tuberculosis.  Structural  changes  generally  com- 
mence and  increase  to  a  certain  extent  without  giving  any  obvious  mani- 
festations of  their  existence;  the  system  tolerates  them,  provided  it  has 


1863.]  Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  35 

nothing  else  to  bear.  But  when  other  circumstances  occur  to  disturb  or 
weaken  the  economy,  an  affection,  up  to  this  time  latent,  declares  itself. 
If  now  the  practitioner  impute  everything  to  the  local  affection,  he  will  be 
much  in  error.  Let  him  succeed  in  restoring  the  system  to  the  state  in 
which  it  was  prior  to  the  manifestations  of  the  affection,  and  the  latter 
may  again  become  comparatively  innocuous. 

A  striking  illustration  of  the  influence  of  associated  circumstances  in 
exaggerating  the  effects  of  a  local  affection  is  sometimes  afforded  by  the 
coexistence  of  anaemia  and  cardiac  lesions.  A  patient  with  this  combination 
of  affections  may  present  palpitation,  dyspnoea,  and  general  dropsy,  so  that 
a  fatal  termination  may  seem  to  be  near  at  hand.  But,  by  removing  the 
anaemic  state,  the  effects  of  the  disease  of  heart  disappear,  and  the  patient 
appears  to  recover  so  fully  that,  were  it  not  for  the  testimony  of  physical 
signs,  the  existence  of  the  cardiac  lesions  would  not  be  suspected.  Exam- 
ples of  this  kind  have  repeatedly  fallen  under  my  observation.  Other 
examples  and  considerations  might  be  adduced  to  show  how  much  conserv- 
atism can  sometimes  accomplish  by  enabling  the  system  to  bear  up  under 
local  affections,  the  continuance  of  which  is  inevitable  :  but  I  must  hasten 
to  another  division  of  the  subject. 

Disorders  occurring  independently  either  of  inflammation  or  appreciable 
lesions,  and,  therefore,  distinguished  as  functional,  differ  as  regards  their 
pathological  import.  A  correct  interpretation  is  necessary  to  a  full  under- 
standing of  rational  indications.  Yomiting  and  purging,  for  example,  in 
the  course  of  Bright's  disease,  have  a  special  meaning  which  the  researches 
of  Bernard  and  others  have  enabled  us  to  understand.  They  show,  in  that 
connection,  the  conservatism  of  Nature,  the  object  being  to  eliminate  vica- 
riously the  urea  which  accumulates  in  the  blood  in  consequence  of  its  defi- 
cient excretion  by  the  kidneys.  The  conservative  physician  thus  follows 
the  guidance  of  nature  when  he  endeavours  to  relieve  the  system  of  this 
excrementitious  principle  by  remedies  which  act  upon  the  gastro-intestinal 
mucous  membrane;  and  he  would  violate  conservatism  were  he  to  attempt 
to  arrest  these  symptoms  of  disorder  of  the  digestive  organs.  In  most 
instances,  however,  disorders  of  functions  either  have  not  so  definite  a  sig- 
nificance as  this,  or  our  present  knowledge  does  not  enable  us  to  interpret 
them  fully ;  and  hence  the  practitioner  must  derive  his  indications  from 
certain  general  principles. 

Functional  disorders  involve,  for  the  most  part,  morbid  conditions  of  the 
nervous  system.  And  these,  when  not  produced  directly  by  over -exercise 
or  over-excitation,  generally  involve  a  prior  abnormal  state  of  the  blood. 
This  is  a  capital  fact  as  regards  therapeutical  indications.  The  nervous 
system,  as  a  generator  of  force,  is  powerless,  and  all  its  vital  functions  are 
speedily  lost,  without  the  presence  of  oxygenated  blood.  How  quickly  are 
the  power  of  willing,  the  faculty  of  feeling,  and  consciousness  suspended 


36     Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  [Jan. 

by  the  deficient  supply  of  blood  to  the  brain  in  syncope !  The  blood  is  the 
medium,  on  which  the  nervous  system  is  as  dependent  for  the  capacity  to 
perform  its  functions,  as  the  body  on  the  atmosphere  for  the  continuance 
of  life.  It  is  not  strange,  therefore,  that  deviatioos  from  the  normal  com- 
position of  the  blood  should  occasion  disturbance  of  the  functions  of  the 
nervous  system.  But  the  effects  of  certain  poisons  upon  the  nervous  sys- 
tem, when  introduced  into  the  blood  in  exceedingly  minute  quantities,  are 
truly  wonderful.  A  fraction  of  a  grain  of  strychnia  acts  upon  the  motor 
nerves,  leaving  the  mental  faculties  intact,  and  gives  rise  to  epileptiform 
convulsions;  a  similarly  minute  quantity  of  woorara  paralyzes  the  nerves 
of  motion ;  a  few  inhalations  of  the  vapour  of  chloroform  extinguish  the 
faculty  of  feeling  pain ;  a  few  drops  of  the  tincture  of  the  veratrum  viride 
reduces,  in  a  notable  degree,  the  frequency  of  the  heart's  action ;  an  amount  of 
atropia  almost  inappreciably  minute  suffices  to  paralyze  the  circular  fibres 
of  the  iris  :  these  are  some  of  the  well-known  manifestations  of  an  astou- 
ishing  susceptibility  of  the  nervous  system  to  the  action  of  certain  morbific 
agents  contained  in  the  blood  in  exceedingly  small  quantities.  The  facts 
just  stated  (of  which  it  is  only  necessary'to  remind  the  reader)  are  valuable 
as  shedding  light  on  the  interpretation  of  various  functional  disorders. 

An  impoverished  state  of  the  blood  stands  in  a  causative  relation  to  various 
functional  disorders.  Clinical  experience  teaches  that  most  of  the  neuroses, 
together  with  various  disorders,  such  as  palpitation,  dyspepsia,  constipation, 
etc.,  are  often  associated  with  anaemia,  and  disappear  when  the  blood  is  re- 
stored to  its  normal  condition.  It  is  a  general  principle,  then,  in  the  man- 
agement of  functional  disorders,  to  direct  attention  to  the  state  of  the  blood. 
And  here  I  am  led  to  remark,  in  passing,  that  the  improvements  in  practice 
based  on  the  knowledge  and  appreciation  of  anaemia,  acquired  within  the  last 
few  years,  furnish  one  of  the  most  striking  of  the  illustrations  of  conserva- 
tive medicine.  Before  this  condition  of  the  blood  was  understood,  the  affec- 
tions dependent  thereon  were,  of  course,  not  correctly  interpreted,  and  their 
treatment  was  inefficacious  if  not  injurious.  And  the  non-recognition  of 
this  condition  as  coincident  with  a  host  of  affections,  involved  a  want  of  dis- 
crimination in  the  employment  of  the  antiphlogistic  measures,  which  was 
the  source  of  not  a  little  unsuccess  and  injury.  The  anaemic  state  is  a  very 
important  source  of  indications  in  the  treatment  of  functional  disorders ; 
but  there  are  doubtless  other  morbid  conditions  of  the  blood  of  which  our 
present  knowledge  affords  less  precise  information.  Various  functional 
disorders,  as  well  as  inflammations  and  structural  changes,  are  probably 
due  to  toxaemic  conditions  which  remain  to  be  ascertained.  Unknown  poi- 
sons, received  from  without  and  generated  within  the  body,  may  be  the 
source  of  diverse  affections,  the  origin  of  which  we  are  now  unable  to  ex- 
plain. Reasoning  analogically  from  the  effects  of  the  well-known  poisons 
to  which  reference  has  been  made,  we  are  led  to  this  conclusion.  Moreover, 
we  have  already  acquired  knowledge  of  certain  forms  of  toxaemia,  occurring 


1863.]  Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.     3 1 

as  results  of  morbid  actions  within  the  organism.  We  know  that  urea 
accumulating  in  the  blood  acts  as  a  poison  on  the  nervous  centres,  giving 
rise  to  epileptiform  convulsions  and  fatal  coma.  We  know,  too,  that  serous 
and  other  inflammations  are  incidental  to  uraemia.  The  researches  of  Gar- 
rod  appear  to  establish  that  gout  is  due  to  the  accumulation  of  uric  acid 
in  the  blood ;  and  the  ingenious  and  striking  experiments  of  Dr.  Richardson 
go  to  show  that  it  is  lactic  acid  which  gives  rise  to  the  articular  affection 
and  to  endocarditis  in  acute  rheumatism.  May  we  not  expect  from  re- 
searches in  this  direction  developments  which  will  shed  new  light  on  the 
production  of  other  affections,  and  furnish  important  therapeutical  indica- 
tions? Assuming,  for  example,  that  cholesterine  is  an  important  excre- 
mentitious  product  produced  in  the  brain  and  nerve  tissue,  and  eliminated 
by  the  liver,  it  may  be  found  that  a  deficient  excretion  of  this  substance  is 
the  source  of  a  toxemic  condition  which  has  important  pathological  rela- 
tions; and  we  may  find  that  there  is  a  substratum  of  scientific  truth  in  the 
vague  notions  of  biliousness  with  which  the  professional  and  popular  mind 
have  been  so  long  and  strongly  imbued.  Cholestersemia  is  one  of  many 
analogous  conditions  of  the  blood  which  are  yet  to  be  revealed  and  clinic- 
ally studied. 

Reasoning  from  the  analogy  between  the  effects  of  certain  poisons  and 
the  phenomena  of  certain  functional  affections,  it  is  reasonable  to  attri- 
bute the  latter  to  a  toxical  source.  For  example,  the  phenomena  of  epilepsy 
bear  so  much  similarity  to  the  effects  of  strychnia,  that  the  convulsions 
produced  by  this  poison  are  said  to  be  epileptiform ;  and  this  is  true  also  of 
the  convulsions  incidental  to  uraemia.  Now,  taking  into  view  the  clinical 
history  of  epilepsy — convulsive  paroxysms  of  brief  duration,  recurring  at 
variable  intervals,  the  patient  often  perfectly  well  just  before  and  immediately 
after  the  paroxysm— how  much  more  probable  is  it  that  a  poison  is  gene- 
rated somewhere  in  the  body,  and  manifests  itself  by  a  powerful  transient 
action  on  the  nervous  centres,  than  that  the  phenomena  are  due  to  any 
mere  disturbance  of  the  circulation  or  to  slight  changes  in  the  consistence 
of  the  medulla  oblongata  such  as  are  described  by  Yon  cler  Kolk.  What 
a  blessing  would  be  the  discovery  of  the  nature  and  source  of  the  toxcemic 
condition  giving  rise  to  epilepsy  and  the  means  of  preventing  the  production 
of  the  poison  ! 

The  highest  aim  of  conservative  medicine  in  all  affections  involving  toxse- 
mia  from  morbid  actions  within  the  body  is  expressed  in  the  foregoing 
sentence.  It  is  to  obviate  the  production  of  the  poisons.  But  first  of  all, 
the  sources  of  toxaemia  must  be  ascertained  and  the  conditions  under  which 
its  different  forms  are  produced.  Here  is  a  field  of  research  from  which 
much  is  to  be  hoped  for,  but  from  which  it  is  needless  to  say  little  has  been 
as  yet  acquired.  The  aims  of  conservatism,  next  in  importance  to  the  one 
just  stated,  are,  knowing  the  nature  of  different  poisons,  together  with  the 
means  of  their  destruction  or  expulsion  from  the  body,  and  recognizing 


38     Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  [Jan. 

their  existence  in  the  blood  as  early  as  possible,  to  effect  either  their  neu- 
tralization or  elimination. 

I  shall  pass  by  the  class  of  diseases  which  I  have  distinguished  as  dia- 
thetic with  a  very  few  words.  The  meaning  of  the  term  diathesis,  which 
is  used  in  a  variable  and  often  an  indefinite  sense,  I  would  here  limit  to 
denote  a  special  state  of  conformation  or  of  the  constitution,  which,  under 
requisite  causative  conditions,  determines  the  occurrence  of  a  particular 
form  of  disease ;  in  other  words,  an  intrinsic  aptitude  of  the  organism  to 
the  development  of  certain  affections.  This  diathetic  condition  may  be 
innate  or  acquired,  and  it  is  often  inherited.  In  this  sense  scrofula,  tuber- 
culosis, asthma,  rheumatism,  gout,  are  diathetic  affections.  In  what  con- 
sists the  diathetic  state  our  existing  knowledge  does  not  enable  us  to  say. 

Conservatism  would  dictate  the  importance  of  removing  the  state  if  it 
be  practicable.  But  it  is  evident  this  is  not  to  be  done  by  medication,  for 
the  existence  of  a  diathesis  is  not  inconsistent  with  health  ;  and,  moreover, 
we  have  not  the  means  of  determining  with  positiveness  the  existence  of  a 
diathesis  until  it  has  eventuated  in  the  development  of  disease.  That  a 
diathetic  state  maybe  held  in  permanent  abeyance  we  have  every  reason  to 
believe.  This  is  accomplished  more  by  hygiene  than  by  therapeutical  influ- 
ences, viz :  by  climate,  habits  of  life,  and  avoidance  of  the  causative  condi- 
tions which  render  active  a  latent  diathesis.  This  division  of  the  subject  is 
by  no  means  lacking  in  interest  and  importance,  but  the  space  already  occu- 
pied warns  me  not  to  enter  more  fully  into  it.  Besides,  the  considerations 
which  are  suggested  under  this  head  relate  more  especially  to  hygiene,  and 
the  application  of  conservative  medicine  to  this  department  of  medical 
practice  does  not  enter  into  the  scope  of  the  present  essay. 

So  far,  the  subject  of  this  essay  has  been  considered  in  the  first  of  the 
two  aspects  under  which  it  is  to  be  regarded,  viz  :  "  The  therapeutical 
indications  derived  from  our  knowledge  of  the  pathological  character, 
causation,  etc.,  of  diseases."  It  remains  to  notice  the  second  aspect,  viz: 
"The  general  objects  of  remedial  measures."  These  two  divisions  of  the 
subject  are  correlative  ;  therapeutical  indications  and  therapeutical  objects 
are,  of  course,  mutually  involved,  but  new  considerations  arise  in  looking 
at  the  subject  from  the  latter  point  of  view.  I  shall  content  myself  with 
endeavouring  to  classify  the  objects  of  remedial  measures,  and  offering  a  few 
remarks  under  the  head  of  each  class.  The  conservative  physician  places 
before  himself  certain  general  objects  in  dealing  with  diseases;  what  are 
these  objects  ?  They  may  be  embraced  in  five  classes  : — 

1.  The  first  object  is  prophylaxis.  Diseases  may  sometimes  be  pre- 
vented. It  is  not  strictly  appropriate  to  call  this  a  therapeutical  or  reme- 
dial object,  but  in  so  far  as  medicinal  agents  are  employed  for  the  prevention 
of  diseases,  the  object  falls  within  the  province  of  the  therapeutist,  and  the 
incongruity  is  merely  in  the  use  of  terms  which  imply  that  disease  already 


1863.]  Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  39 

exists.  Excluding  preventive  measures  which  are  properly  surgical,  such 
as  the  cauterization  of  poisoned  wounds,  etc.,  known  prophylactic  remedies 
are  not  abundant.  In  fact,  we  are  limited  to  a  few  examples.  The  pro- 
tective efficacy  of  quinia  against  intermittent  fever  may  be  considered  as 
sufficiently  established.  Alcohol  appears  to  protect  the  system  against 
certain  venoms.  The  protective  power  of  alcohol  against  tuberculous  dis- 
ease is  a  question  sub  judice,  and  one  may  well  dread  the,  settlement  of  the 
question  in  the  affirmative.  The  antidotes  to  poisons  in  the  stomach  are 
preventives  of  the  diseases  which  they  would  produce  if  not  neutralized. 
In  like  manner,  we  might  hope  to  discover  antidotes  to  hsemic  poisons, 
were  we  acquainted  with  their  nature,  and  aware  of  their  existence  prior 
to  the  production  of  the  affections  to  which  they  give  rise.  Doubtless  by 
judicious  management  secondary  affections  may  sometimes  be  prevented. 
Thus,  by  favouring  the  elimination  of  urea,  in  uraemia,  either  through  the 
kidneys  or  the  alimentary  canal,  we  may  prevent,  for  a  time  at  least,  inflam- 
mations, convulsions,  and  fatal  coma;  and  by  restraining  the  excretion  of 
albumen  with  the  urine,  we  may  prevent  the  occurrence  of  dropsy.  Other 
instances  of  this  kind  of  prophylaxis  might  be  cited ;  but  it  is  evident  that 
what  we  may  accomplish  is,  for  the  most  part,  only  a  matter  of  reasonable 
conjecture,  and  could  not  be  established  by  positive  proof.  It  is  a  curious  fact 
that  certain  affections  appear  to  be  prophylactic  as  regards  others.  Asth- 
matic persons  very  rarely  become  tuberculous.  The  same  is  true  of  persons 
affected  with  organic  lesions  of  the  heart.  Tuberculous  patients  seem  to 
be  insusceptible  to  the  special  cause  producing  typhoid  fever.  Acute 
rheumatism  and  tubercle  are  not  often  associated.  Other  illustrations 
might  be  cited.  The  incompatibility  of  certain  diseases,  however,  can 
hardly  be  made  available  in  practice ;  and,  in  short,  our  expectations  from 
the  future,  as  regards  the  discovery  of  prophylactic  medicinal  agents  must 
needs  be  small  were  they  to  be  measured  by  what  has  been  already 
discovered. 

2.  A  second  object  is  the  arrest  of  diseases.  To  arrest  diseases  in  limine, 
cut  them  short,  or,  in  the  significant  language  of  some  French  writers, 
jugulate  them,  is,  obviously,  an  object  in  desirableness  ranking  next  to 
prophylaxis.  But  as  regards  the  extent  to  which  this  is  practicable,  how 
different  the  popular  belief  from  the  present  views  of  the  best  informed 
members  of  the  profession  !  The  notions  of  the  public  concerning  medical 
matters  generally  emanate  from  the  profession,  and  the  reason  why  patients 
expect  diseases  to  be  arrested  is,  the  ability  to  do  it  has  been  assumed  by 
physicians.  It  is  not  long  since  physicians  conscientiously  believed  that 
they  often  strangled  diseases  which  now  they  are  content  to  allow  to  run 
their  course.  It  is  only  a  few  years  ago  that  inflammations  and  most  of 
the  essential  fevers  were  considered  to  be  amenable  to  what  have  been  called 
abortive  measures  of  treatment.  Popular  notions  are  not  readily  changed, 
and,  with  respect  to  this  point,  our  knowledge  is  simply  in  advance  of 


40     Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  [Jan. 

public  faith.  But  why  is  it  that  physicians  were  formerly  self-deceived  in 
this  regard  ?  Chiefly  because  the  art  of  diagnosis  had  not  been  brought 
to  such  perfection  as  it  has  been  within  the  past  few  years.  Patients 
with  an  attack  of  pleurodynia  or  intercostal  neuralgia,  for  example,  were 
often  thought  to  have  acute  pleurisy  or  pneumonia.  A  copious  venesection, 
an  active  purge,  and  a  blister,  appeared  to  check,  at  once,  the  progress  of 
the  inflammation.  The  pain  was  in  fact  suspended,  and  although  the 
recovery  from  the  effects  of  the  remedies  may  have  been  slow,  the  treatment 
appeared  to  be  signally  successful.  Neuralgic  affections  had  been  com- 
paratively but  little  studied,  and  were  often  confounded  with  inflammatory 
affections.  Practitioners  thought  that  they  contended  with  inflammation 
of  the  bowels  and  brain  much  oftener  than  now.  Ephemeral  fevers  were 
considered  to  be  examples  of  continued  fever  broken  up.  As  we  have  im- 
proved in  diagnosis,  the  resources  of  therapeutics  have  seemed  to  be  cur- 
tailed. Yet,  what  an  improvement  is  it  that  the  active  treatment  formerly 
in  vogue  to  arrest  many  diseases,  is  no  longer  resorted  to  for  that  end  ! 
Conservative  medicine  has  here  gained  much  in  the  way  of  protecting  the 
body  against  the  evils' of  needless  therapeutical  measures. 

On  the  other  hand,  conservative  medicine  has  gained  much  in  the  way 
of  abortive  treatment  in  certain  affections.  The  periodical  fevers  are 
arrested  with  much  more  promptness  and  certainty  than  some  years  ago. 
This  is  true  of  certain  functional  disorders,  such  as  colic,  cholera  morbus, 
and  certain  forms  of  neuralgia,  by  means  of  the  bolder  use  of  certain  reme- 
dies, especially  quinia  and  opium.  We  can  count  on  the  arrest  of  some 
diseases,  but  it  must  be  confessed,  the  number  is  very  limited,  not  embrac- 
ing those  which  are  the  most  frequent,  viz  :  inflammations  and  other  than 
the  periodical  fevers.  Here  is  ample  scope  for  future  discoveries  which 
may  enlarge  beyond  our  present  powers  of  calculation  the  resources  of 
practical  medicine. 

3.  A  third  object  is  the  cure  of  diseases.  I  use  the  word  cure  in  its 
conventional  sense.  From  its  etymology  it  should  denote  simply  the  care 
(cura)  of  the  sick.  And  the  latter  signification  expresses  the  true  func- 
tion of  the  physician.  His  business  is  to  take  care  of  the  sick,  which 
means,  watching  the  course  of  disease,  applying  the  art  of  diagnosis  and 
of  prognosis,  bringing  to  the  bedside  his  knowledge  of  the  natural  history 
and  laws  of  different  affections,  regulating  hygienic  conditions,  exercising  a 
proper  moral  influence,  and  prescribing  remedial  agents  where  these  are 
required.  Thanks  in  behalf  of  the  character  of  the  profession,  medical 
practice  bids  fair  to  become  something  higher  in  the  estimation  of  the  pub- 
lic than  the  administration  of  drugs  !  The  time  is  coming  when  the  idea 
of  the  doctor  will  be  less  inseparably  associated  than  heretofore  with 
the  lancet  and  pill  box  !  But  using  the  term  cure  in  its  conventional 
sense,  it  means  the  exercise  of  a  controlling  influence,  to  a  greater  or  less 
extent,  over  diseases.    And  as  an  object  of  therapeutics,  the  curative 


1863.]   Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  41 

treatment  will  embrace  measures  which  abridge  the  duration  of  diseases, 
diminish  their  severity,  or  which  influence  favourably  their  progress  in 
any  manner  and  conduce  to  a  favourable  termination. 

As  with  the  arrest,  so  with  the  cure  of  diseases,  the  efficiency  attributed 
to  therapeutical  interference  would  seem  to  have  decreased  in  proportion  as 
our  knowledge  has  advanced.  Physicians  formerly  congratulated  them- 
selves on  curing  diseases  which  ceased  by  their  own  limitations,  and  which 
had  no  tendency  to  a  fatal  result.  The  recovery  was  considered  as  proof 
of  a  cure  having  been  effected,  and  that  they  were  not  indefinitely  pro- 
longed, was  evidence  of  their  duration  having  been  abridged.  The  study 
of  the  natural  history  of  diseases  within  the  last  few  years  has  led  to  the 
knowledge  of  the  laws  of  self-limitation,  and  of  the  amount  of  danger 
which  belongs  to  them  intrinsically.  The  consequence  is,  the  physician  is 
content  to  assume  to  be  more  the  servant,  and  less  the  master  of  nature. 
He  undertakes  less,  and  nature  has  the  opportunity  of  accomplishing  more. 
Here,  too,  popular  belief  has  not  kept  pace  with  the  improvement  of  medi- 
cine, and  patients  are  often  not  satisfied  to  be  taken  care  of,  but  expect  to 
be  cured.  Unquestionably,  cases  of  disease  are  better  managed  now  than 
heretofore,  and  the  improvement  involves,  in  part,  less  reliance  on  certain 
therapeutical  agents  which  were  formerly  considered  as  curative.  I  refer 
more  particularly  to  the  so-called  antiphlogistic  measures.  We  should 
not  hesitate  to  acknowledge  this  fact.  It  is  certainly  no  disparagement  to 
medicine  that  it  has  improved,  and  it  must  be  expected  that  improvement 
will  consist,  measurably,  in  the  correction  of  errors,  as  well  as  in  newly 
acquired  resources.  But  the  improvement  is  by  no  means  wholly  of  this 
negative  character ;  it  consists,  measurably,  in  the  employment  of  more 
efficient  curative  treatment.  Of  the  latter,  the  free  use  of  opium  in  acute 
inflammations,  and  especially  in  acute  peritonitis,  is  the  most  prominent 
example.  The  use  of  large  doses  of  the  iodide  of  potassium  in  syphilitic 
periostitis,  and  in  some  of  the  forms  of  chronic  inflammation,  and  of  quinia 
as  a  curative  remedy  in  remitting  and  yellow  fever,  and  in  certain  cases  of 
neuralgia,  may  also  be  cited  in  the  same  category. 

The  antiphlogistic  measures  of  treatment  were  formerly  employed  too  in- 
discriminately because  inflammations  were  not  accurately  discriminated  from 
other  affections  ;  and  too  freely  because  undue  reliance  was  placed  on  their 
curative  influence.  What  is  the  correct  estimate  of  their  efficiency  ?  This 
is  a  question  which  every  reflecting  physician  cannot  but  have  propounded 
to  himself.  Do  bleeding,  cathartics,  antimony  and  other  sedatives,  mercu- 
rialization,  etc.,  exercise  curative  influence  over  acute  inflammation  ?  Do 
they  contribute  nothing  toward  diminishing  the  intensity  of  inflammation, 
shortening  its  duration,  limiting  the  amount  of  exudation,  and  favouring 
resolution  ?  If  not,  these  measures  always  do  harm,  and  should  never 
enter  into  the  treatment  of  inflammation.  There  are  observing  and  think- 
ing physicians  who  adopt  the  latter  view,  and  there  are  those  who  still 


42     Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  [Jan. 

have  great  faith  in  the  efficacy  of  these  measures.  The  truth  probably  lies 
between  these  extremes.  For  one,  I  am  not  prepared  to  ignore  entirely 
the  experience  of  candid,  sagacious  observers  for  many  past  generations. 
I  believe  that  these  measures  may  exert  a  certain  amount  of  curative  influ- 
ence, and  that  whether  they  do  harm  or  good  depends  on  the  discrimination 
with  which  they  are  employed.  If  resorted  to  injudiciously,  the  harm  will 
preponderate  over  the  good ;  and  if  judiciously  employed,  their  use  will 
undoubtedly  be  much  restricted  as  compared  with  the  past. 

This  train  of  remark  has  opened  up  a  large  topic  which  I  cannot  here 
discuss.  I  shall  leave  it  after  pointing  out  a  highly  important  practical 
application  of  the  juste  milieu  doctrine  with  regard  to  antiphlogistic 
measures.  And  I  am  led  to  make  this  application  because  it  involves,  as 
it  seems  to  me,  a  nice  exemplification  of  conservatism.  There  are  certain 
inflammations,  to  which  reference  has  been  already  made,  which  destroy 
life,  not  from  their  extent  or  intensity,  but  from  circumstances  incidental 
to  their  situation.  This  is  true  of  acute  laryngitis.  The  same  amount  of 
inflammation  situated  elsewhere,  would  be  trifling  ;  here  it  is  fatal  by  caus- 
ing obstruction  at  the  larynx.  Capillary  bronchitis  is  an  analogous  ex- 
ample ;  the  danger  is  from  the  obstruction  of  the  small  bronchial  tubes. 
Acute  meningitis  is  another  example  ;  the  danger  is  chiefly  from  compres- 
sion by  the  products  of  inflammation.  Patients  die  from  these  inflamma- 
tions by  apnoea.  On  the  other  hand,  the  source  of  danger  in  inflammations 
situated  elsewhere  is,  generally,  in  the  disturbance  of  the  system  and  failure 
of  the  vital  forces.  Patients  die  in  most  cases  by  asthenia.  Now,  in  the 
latter  inflammations,  the  evils  of  the  antiphlogistic  measures  have  reference 
to  the  source  of  danger  and  the  mode  of  dying ;  and  the  problem  is,  to 
determine  whether  the  curative  influence  of  these  measures,  as  regards  the 
local  affection,  will  overbalance  their  effect  on  the  powers  of  life,  or  vice 
versa.  In  the  one  case  good,  and  in  the  other  case  harm,  will  preponde- 
rate. But  in  the  former  inflammations  there  is  not  the  same  need  of 
sparing  the  powers  of  life.  The  danger  is  not  from  the  giving  way  of 
these.  Hence,  we  may  consider  chiefly,  in  such  cases,  the  curative  influence 
of  antiphlogistic  measures  as  regards  the  local  affection;  or,  in  other 
words,  we  have  not  to  balance  the  probabilities  of  good  or  harm  as  in  the 
previous  problem,  but  simply  to  secure  all  the  good  to  be  obtained  by  their 
judicious  employment.  This  mode  of  reasoning  will  be  likely  to  lead  to 
the  continued  use,  to  a  greater  or  less  extent,  of  antiphlogistic  measures  in 
certain  inflammations,  albeit  their  use  may  be  generally  abandoned  as  either 
unnecessary  or  as  doing  more  harm  than  good. 

The  fourth  object  is  palliation.  Palliative  measures  enter  largely  into 
the  management  of  diseases.  They  mainly  constitute  the  treatment  in  two 
classes  of  cases :  first,  in  those  in  which  the  disease  pursues  a  favourable 
course  without  the  need  of  active  interference ;  and,  second,  in  those  which 
offer  no  encouragement  for  curative  treatment.    Relief  of  pain  or  distress 


1863.]   Flint,  Conservative  Medicine  as  Applied  to  Therapeutics.  43 

is  an  important  object  of  treatment  irrespective  of  the  issue  of  a  disease ; 
and  it  is  to  be  reckoned  among  the  recent  improvements  in  practice  not 
least  in  importance,  that  physicians  are  not  now  to  be  restrained,  as  they 
have  been,  in  the  use  of  opium  and  other  anodyne  remedies,  by  apprehen- 
sions of  their  unfavourable  influence  on  the  progress  of  various  affections. 
We  hear  much  less  nowadays  than  formerly  of  the  danger  of  producing 
cerebral  congestion  or  locking  up  the  secretions  by  opiates,  notions  which 
often  deprived  patients  of  the  comfort  and  advantage  to  be  derived  from 
their  use.  Palliative  measures,  although  addressed  to  symptoms,  and  not 
to  the  disease  per  se,  may,  nevertheless,  be  to  a  greater  or  less  extent  cur- 
ative by  diminishing  the  general  disturbance  and  consequent  exhaustion 
incidental  to  the  continuance  of  suffering. 

The  fifth  object  is  support.  Pre-eminent  among  the  characteristics  of 
conservative  practice  is  the  employment  of  supporting  measures  in  all  cases 
of  any  disease,  whatever  be  its  name,  character,  or  situation,  in  which 
danger  from  failure  of  the  powers  of  life  is  to  be  looked  for.  Of  the  im- 
portance of  this  object  enough  has  been  already  said  in  the  course  of  the 
foregoing  remarks.  Suffice  it  to  add  a  consideration  having  reference  to 
the  value  of  support  in  cases  which  are  unattended  with  danger  to  life.  In 
emerging  from  an  acute  disease  of  any  kind,  a  patient  who  has  been  judi- 
ciously supported  by  tonics,  nutritious  food,  and,  if  need  be,  alcoholics, 
enters  upon  convalescence  with  vigour  of  body  and  mind  far  less  impaired 
than  if  this  object  of  treatment  had  not  received  appropriate  attention,  and 
the  complete  restoration  is  more  rapid.  A  comparison  of  the  condition  of 
patients,  now  and  formerly,  after  the  termination  of  diseases  in  conva- 
lescence and  recovery,  would  perhaps  afford  a  stronger  contrast  illustrative 
of  improvement  in  practice,  than  a  comparison  of  the  rates  of  mortality. 
This  contrast  is,  in  part,  due  to  differences  pertaining  to  the  employment 
of  curative  measures  of  treatment,  but,  in  no  small  measure,  also,  to  differ- 
ences of  management  as  regards  supporting  measures. 

The  foregoing  classification  of  therapeutical  objects  does  not  embrace, 
distinctly,  a  class  of  measures  which  hardly  ranks  inferior  to  any  in  its 
bearing  on  the  management  of  diseases.  I  refer  to  sanitary  or  hygienic 
measures,  relating  to  air,  temperature,  diet,  cleanliness,  climate,  moral  in- 
fluences, etc.  The  subject  of  this  essay  embraces  only  considerations  re- 
lating to  therapeutics.  Conservative  medicine,  as  applied  to  hygiene,  is 
a  subject  not  less  fruitful  in  practical  considerations.  This  subject  is 
reserved  for  a  future  essay. 


44 


Fisher,  Cases  of  Amputations. 


[Jan. 


Art.  III. — Report  of  Fifty -seven  Cases  of  Amputations,  in  the  Hospitals 
near  Sharpsburg,  Md.,  after  the  Battle  of  Antietam,  September  11, 1862. 
By  G.  J.  Fisher,  M.  D.,  of  Sing  Sing,  N.  Y. 

The  battle  of  Antietam  was  fought  on  Wednesday,  September  11,  1862. 
The  aggregate  loss  of  both  armies,  estimated  approximately,  in  round 
numbers,  was  5,000  killed  and  20,000  wounded.  In  their  retreat  across 
the  Potomac,  the  enemy  left  between  fourteen  and  fifteen  hundred  of  their 
more  severe  cases  of  wounded  to  the  tender  mercies  of  the  victors.  They 
were  crowded  into  farm-houses,  barns,  stables,  sheds,  and  negro  shanties, 
with  more  or  less  straw  or  hay  beneath  them,  as  they  had  been  brought  off 
from  the  field  of  battle.  Every  building  in  the  region  had  been  thus  ap- 
propriated, regardless  of  its  location,  salubrity,  capacity,  convenience,  or 
adaptation  to  the  purpose  in  any  other  particular  except  as  affording  a 
shelter,  more  or  less  complete,  from  the  direct  rays  of  the  sun  or  from  rain. 

Dr.  Letterman,  Medical  Director  of  the  Army  of  the  Potomac,  had  de- 
tailed Dr.  Roche,  IT.  S.  A.,  to  take  the  general  charge  of  all  the  prisoners. 
Dr.  R.  soon  ascertained  that  there  was  a  deficient  force  of  rebel  surgeons 
to  give  proper  attention  to  their  wounded ;  he  accordingly  sent  to  their 
aid  a  number  of  Union  volunteer  surgeons.  The  writer  was  among  the 
number,  and  was  placed  in  charge  of  Kershaw's  brigade  hospital,  which 
was  but  a  portion  of  MeClain's  division  hospital,  containing  over  two 
hundred  wounded  men.  The  number  of  patients  under  my  exclusive  care 
was  a  little  over  sixty ;  for  this  hospital  (Kershaw's)  one  orderly  had  been 
detailed  as  cook,  and  another  as  attendant  on  the  surgeon.  The  hospital 
*  comprised  one  small  old  farm-house,  without  any  furniture,  not  even  a 
chair,  two  negro  huts,  and  one  cow  stable,  the  earth  floor  covered  to  a 
depth  of  two  feet  with  manure,  the  top  slightly  strewn  with  coarse  straw. 
Most  of  the  hospitals  had  similar  wards.  The  men  were  sadly  deficient  in 
blankets  and  clothing.  Their  personal  condition  was  extremely  wretched ; 
they  were  begrimed  with  filth  and  alive  with  parasites.  Notwithstanding 
their  total  neglect  of  cleanliness,  they  were  almost  invariably  hardy  men, 
capable  of  enduring  great  fatigue  and  privation.  They  were  thoroughly 
inured  to  hardships,  and  had  cheerfully  performed  the  rigid  requirements  of 
their  service.  They  were  not  desponding,  although  they  were  wounded 
and  left  prisoners  in  our  hands.  They  were  grateful  for  the  least  favour, 
and  hopeful  of  recovery.  Such  was  the  general  condition  of  the  rebel 
prisoners  for  several  days  after  the  battle.  The  government,  but  par- 
ticularly the  U.  S.  Sanitary  Commission  agents,  as  soon  as  practicable, 
furnished  a  liberal  supply  of  the  most  essential  articles  for  the  treatment  of 
the  wounded,  including  bed-sacks,  blankets,  clothing,  stimulants,  food,  &c. 
These  needed  supplies,  with  kind  attention,  gave  the  men  great  cheer,  and 
filled  their  hearts  with  gratitude,  which  doubtless  had  a  material  influence 
on  their  recovery.    Before  the  stock  of  carefully  prepared  food  and  stimu- 


1863.] 


Fisher,  Cases  of  Amputations. 


45 


lants  was  received,  the  wounds  indicated  a  deficient  vitality,  which  soon 
changed  under  an  improved  regimen. 

While  engaged  in  the  care  of  the  rebel  wounded,  the  writer  learned  that 
no  records  were  kept  by  the  surgeons,  except  a  list  of  deaths.  Being 
struck,  by  this  neglect,  with  the  loss  of  so  many  valuable  facts,  and  so 
much  material  for  the  formation  of  reliable  statistical  tables,  from  which 
important  principles  and  rules,  if  not  laws,  could  be  deduced  for  future  use 
in  military  surgery,  a  few  minutes  were  set  apart  each  day  for  recording 
the  history  of  interesting  cases  of  wounds,  and  particularly  cases  of  ampu- 
tation and  resection.  The  materials  for  the  following  tables  were  collected  in 
the  houses  in  the  vicinity  of  my  own  hospital.  Had  I  remained  a  week  or 
two  longer,  the  statistics  of  several  hundred  cases  could  have  been  collected, 
without  interfering  with  my  special  daily  duties. 

What  is  most  needed  to  aid  in  this  work  is  a  supply  of  blanks.  The 
following  tables  are  given  as  an  example,  subject  to  such  modifications  as 
the  Surgeon  General  or  Medical  Inspectors  may  think  proper  to  make. 
By  furnishing  a  few  well-arranged  blanks  for  different  classes  of  surgical 
cases  to  each  member  of  the  medical  staff,  a  vast  number  of  facts  would  be 
rescued  from  oblivion,  which,  by  their  accuracy,  being  taken  on  the  spot, 
and  their  uniformity  in  regard  to  the  method  of  record,  would  be  valuable 
contributions  to  our  science  and  art/ 

The  "present  condition"  of  all  the  patients  given  in  the  following 
tables  was  carefully  taken  in  the  afternoon  of  October  1st,  sixteen  days 
after  the  battle.  It  is  admitted  that  the  time  was  rather  short  to  speak 
with  entire  certainty  in  regard  to  prognosis,  yet  it  is  my  opinion  that  all 
will  recover  who  are  there  said  to  be  "doing  well."  The  relative  ad- 
vantage of  primary  and  secondary  amputation  was  clearly  demonstrated 
so  far  as  my  observations  extended.  It  was  gratifying  to  discover  among 
nearly  all  the  surgeons  with  whom  I  had  communication,  especially  those 
who  had  been  over  a  year  in  the  service,  a  growing  or  fixed  principle  of 
action  in  reference  to  this  point.  Many  confessed  that  they  had  learned, 
too  often  by  sad  experience,  that  amputations  had  been  delayed,  under  the 
impression  that  the  shock  of  the  operation,  added  to  the  original  injury, 
would  increase  rather  than  lessen  the  danger  to  the  patient,  and  that  in  the 
mean  time  it  would  perhaps  be  thought  best  to  attempt  to  save  the  limb, 
providing  no  bad  symptoms  ensued.  Macleod,  in  his  Notes  on  the  Surgery 
of  the  Crimea,  says  :  "  The  experience  of  the  Crimea  in  favour  of  early 
operation  was  unequivocal  in  both  armies,  and  needs  no  illustration  from 
me."  He  adds  in  a  note:  "I  am  led  to  understand,  from  a  very  well- 
informed  source,  that  the  Russians  also  lost  two-thirds  of  all  their  second- 
ary operations,  but  sa^ed  a  fair  number  of  their  primary.  " 

I  was  informed  by  the  rebel  surgeons  that  secondary  amputations  were 
much  more  frequent  in  their  early  military  experience  than  at  the  present 
time,  which  corresponds  with  a  statement  of  Macleod  in  his  Notes. 

The  extreme  desire  to  be  conservative,  by  the  sacrifice  of  as  few  limbs  as 


46 


Fisher,  Cases  of  Amputations. 


[Jan. 


possible,  led  to  a  great  number  of  unsuccessful  attempts  to  preserve  more 
or  less  of  an  extremity,  by  resection,  or  trusting  to  the  hope  of  reunion. 
By  far  the  majority  of  resections  after  gunshot  injuries  of  the  bones,  have 
resulted  in  failure,  and  very  few  who  have  watched  the  progress  of  the  case 
now  look  upon  the  operation  with  favour,  but  consider  it  questionable  con- 
servative surgery. 

The  profession,  civil  rather  than  military,  is  still  divided  on  this  subject. 
The  distinction  between  cases  of  disease  and  accident  has  not  been  made 
with  sufficient  clearness,  and  doubtless  this  has  led  to  indecision,  hesitancy, 
and  fatal  delays.  The  accumulated  experience  of  every  recent  war  has 
been  so  uniform  and  positive  on  this  point,  that  it  should  be  regarded 
henceforth  as  a  settled  question,  a  demonstrative,  yes,  a  surgical  law,  that 
in  any  case  where  amputation  is  required  after  a  gunshot  or  other  injury, 
every  hour  the  operation  is  delayed  diminishes  the  chances  of  a  favourable 
issue.  In  regard  to  shock,  which  is  regarded  with  so  much  dread,  and  as- 
signed as  a  reason  for  delay,  it  is  now  well  known  that  it  is  not  established 
for  some  time  after  the  receipt  of  the  injury ;  the  interval  varies  in  different 
cases,  but  is  long  enough  in  most  cases  to  afford  time  for  amputation.  If 
this  "precious  moment,"  as  Macleod  calls  it,  cannot  always  be  seized, 
Longmore  assures  us  that  if  the  "  shock"  is  moderate  in  degree,  this  is  not 
a  sufficient  reason  for  delaying  amputation.  He  adds  :  "A  moderate  ex- 
hibition of  stimulus  and  a  few  consolatory  words  will  often  remove  this, 
and,  even  though  some  faintness,  pallor,  and  depression  remain,  no  ill  con- 
sequences ensue."  In  the  Crimea  the  operation  was  frequently  done  before 
the  shock  had  disappeared,  and  with  impunity.  . 

Longmore  says  :  "  The  introduction,  of  chloroform,  by  its  negative  ope- 
ration of  preventing  pain  or  alarm,  and  by  its  positive  action  as  a  stimu- 
lus, has  done  much  to  remove  many  of  the  objections  which  have  been 
urged  against  early  amputations  after  gunshot  wounds." 

Macleod  gives  his  testimony  of  chloroform  thus :  "  If  we  believe,  as  I 
certainly  do,  that  by  the  use  of  this  anaesthetic  all  fear  of  intensifying  the 
shock  is  obviated — which  was  one  reason  why  surgeons  delayed  operation 
— then  the  tendency  of  military  surgery,  since  the  introduction  of  chloro- 
form, must  be  to  still  earlier  and  more  prompt  interference." 

With  the  excessive  duties  which  an  active  campaign  or  the  results  of  a 
battle  impose  upon  the  surgeons,  it  is  difficult  to  find  time  or  inclination 
to  collect  and  record  materials  for  reliable  statistical  tables.  This  difficulty 
could  be  greatly  overcome  by  the  medical  department  furnishing  blanks, 
with  appropriate  headings  for  all  the  facts  desired  on  any  subject.  In  case 
the  patients  are  removed  from  the  care  of  the  surgeon  who  kept  the  re- 
cord, a  copy  of  the  partial  record  should  be  sent  with  the  patients,  to  be 
completed  as  time  developed  the  desired  information.  I  have  not  learned 
that  any  such  means  have  been  taken  by  the  Surgeon  General  of  the  U.  S. 
army,  and  though  I  pray  God  may  soon  end  this  horrible  civil  war,  yet  it 
may  not  be  too  late  to  issue  proper  blanks,  by  means  of  which  much  valuable 
information  may  be  collected,  whereby  certain  points  may  be  finally  settled. 


1863.] 


Fisher,  Cases  of  Amputations. 


41 


Present  condition  and 

REMARKS. 

Hemorrhage  on  battle-field  ; 

maggots  in  stump. 
Doing  well ;  will  recover. 
Died  on  the  battle-field,  30 

hours  after  wound. 

Gangrene  of  leg  before  am- 
putation was  performed. 

Crowded  hosp.,  bad  air,  &c. 
Doing  well. 

Doing  well ;  same  ball  cut 

off  right  middle  finger. 
Doing  well. 

Leg  infiltrated  with  pus  be- 
fore amputa'n,  which  ope- 
ration should  have  been 
done  immediately  after 
the  wound  was  received ; 
prognosis  doubtful. 

Some  sloughing  has  occur- 
red ;  he  is  now  doing  well. 

Flaps  sloughed. 

Cause 
of 

DEATH. 

Pyemia 

Shock  & 
exhaus- 
tion 
Pyemia 
&  morti- 
fication 

of 
stump 
Pyemia 

Pyemia 
.... 

Pyemia 

Date 
of 

DKATH 

1862 
Sept.  21 

Sept".  19 

"  22 

"  21 
Sept.  30 

Sept.  25 

Point  of 

AMPUTA- 
TION. 

Low.  third 

"  left 

Below  mid. 
Middle 

Low.  third 
Middle 

Mode. 

Flap 

Circular 
Flap 

Circular 

Flap 
Circular 

Flap 

Date  of 

AMPUTA- 
TION. 

GO       ©GO             ©                       t- CO       I>  t-       GO  t-»       ©                             GO  GO 
<M  i-H      <M  i-H           rH                    HH      HH      riH      CM                         i-H  rH 

M  P<     2  2           3                   2333232  2 

w 

Character  of  wound. 

Extensive  wound  of  knee-joint. 

Left  knee-j  oint,  very  badly. 
Patella  shot  off ;  lateral  disloca- 
tion of  head  of  tibia. 

Comminuted  fracture  of  tibia,  and 
wo  und  of  anterior  tibial  artery. 

(Not  ascertained). 

Injury  to  left  knee-joint,  fracture 

of  patella,  &c. 
(Not  ascertained). 
Comminuted  fract.  of  left  femur. 

Passed  through  right  knee-joint. 

Comminuted  fracture  of  right  fe- 
mur just  above  knee-joint. 

Comminuted  fracture  of  left  tibia, 
extending  into  the  knee-joint. 

Comminution  of  left  knee. 

Comminuted  fracture  of  tibia,  ex- 
tending into  right  knee-j  oint. 

Missile. 

Minie  ball 
Shell.frag. 
Minie  ball 

Minie  ball 
Gr'pe  shot 

•HXTY3H 

snoiAaHj 

1     2  2           3                   3  3       2  3       3  3       2                       2  1 

Nativi- 
ty. 

03 
o 

■B    .  .        »    „, 

a 

Regi- 
ment. 

13  Miss. 

13  " 

17  " 

18  " 

18  " 
18  " 

15  Va. 
15  " 

32  " 
10  Ga. 

53  " 

1  S.C. 
7  " 

Rank. 

Private 

Lieut. 

Private 

Serg'nt- 
major 
Private 
Lieut. 

Private 
<< 

iJV    |        M       cqtN            <M                      COH       NM       NM       N  COCO 

Name. 

Alf'd  "Williams 

Jesse  W.  Young 
J.  McNutt 

J.  G.  Rainwater 

R.  Lence 

W.  R.  Bryant 

John  B.  Rate 
Wm.  H.  Brigs 

Thomas  Rudd 
 McNeal 

J.  G.  Tate 

J.  B.  Burnett 
F.  M.  Cantrell 

i— I      CN  CO  "O  ©      I>  GO      ©  ©      i-H  CN  CO 


43 


Fisher,  Cases  of  Amputations. 


[Jan. 


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Fisher,  Cases  of  Amputations. 


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50  Fisher,  Cases  of  Amputations.  |  [Jan. 

The  whole  number  of  cases  of  amputations,  given  in  the  above  tables, 
is  fifty-seven ;  the  mortality,  including  two  cases  where  the  prognosis  is 
noted  as  doubtful,  amounts  to  eleven,  the  percentage  being  19.47. 

Of  the  lower  extremities  there  are  twenty-nine  cases,  of  which  eight  were 
fatal,  if  we  include  the  two  cases  of  doubtful  prognosis;  the  fatality  being 
27.58  per  cent. 

There  are  twenty-eight  cases  of  amputations  of  the  upper  extremities, 
three  resulted  fatally,  10.71  per  cent. 

Of  amputations  of  the  thigh  thirteen  cases  are  given,  seven  were  fatal, 
including  one  of  doubtful  prognosis,  mortality  53.84  per  cent. 

Sixteen  amputations  of  the  leg  are  recorded  with  one  fatal  case,  6.25  per 
cent.  This  fatal  case  was  still  living  (Case  8),  it  was  by  no  means  certain 
that  he  would  die  ;  should  he  recover,  we  would  have  sixteen  cases  of  am- 
putation of  the  leg,  and  no  fatal  result. 

Amputation  at  the  shoulder-joint  was  performed  in  only  four  cases,  one 
died;  mortality  25.00  per  cent. 

The  arm  was  amputated  in .  twenty  cases,  of  which  two  patients  died ; 
10.00  per  cent. 

The  amputations  of  the  forearm  were  all  successful. 

With  regard  to  the  "  mode"  of  performing  the  amputations,  twenty-nine 
were  by  flaps  ;  viz.,  thigh  four,  leg  nine,  shoulder-joint  four,  arm  ten,  fore- 
arm two.  The  circular  method  was  resorted  to  in  twenty-eight  cases ;  under 
this  head  are  included  the  ordinary  circular,  and  the  more  decidedly  conical 
mode;  viz.,  thigh  circular  nine,  leg  circular  six,  conical  one  (=  7)  ;  arm 
circular  eight,  conical  two  (=  10). 

Of  the  twenty-nine  flap  operations,  five  were  fatal,  17.02  per  cent. 

Of  the  twenty -eight  circular  operations,  six  were  fatal,  20.68  per  cent. 

The  four  cases  of  secondary  amputation  were  all  fatal ;  it  is  quite  pro- 
bable that  they  would  have  recovered  had  the  operation  been  done  imme- 
diately after  the  receipt  of  the  wounds. 

The  projectiles  or  missiles  inflicting  the  injuries,  as  far  as  could  be  ascer- 
tained, were  minie  balls  in  forty -two  instances,  75.00  per  cent. ;  grape  shot 
in  seven  cases,  12.50  per  cent.  ;  fragments  of  shell  in  six,  =  10.71  per  cent. ; 
musket  ball  in  one,  1.78  per  cent.  In  thirty  of  the  cases  joints  were  directly 
implicated  (54.54  per  cent.) ;  viz.,  knee-joint  eight,  ankle-joint  five,  shoulder- 
joint  one,  elbow-joint  fourteen,  wrist-joint  two. 

In  several  other  cases,  the  injury  is  recorded  in  the  tables  as  a  comminu- 
tion of  the  bones  near  the  joints.  In  all  the  cases  of  amputation  a  serious 
lesion  of  one  or  more  bones  had  resulted  from  the  projectile,  in  no  case  had 
the  operation  been  done  without  the  most  imperative  necessity. 

In  the  fifty-one  cases  where  it  was  ascertained  which  side  of  the  body 
received  the  injuries,  twenty-eight  were  on  the  right  side;  viz.,  six  of  the 
thigh,  ten  of  the  leg,  and  fourteen  of  the  upper  extremities. 

In  twenty-three  cases  the  injury  was  received  on  the  left  side;  viz.,  thigh 
five,  leg  six,  upper  extremities  twelve. 


1863.] 


Do  well,  Trismus  Nascentium. 


51 


The  nativity  exhibits  fifty-two  Americans,  three  Germans,  and  two  Irish. 

In  reference  to  ages,  the  youngest  soldier  was  sixteen  years  of  age,  the 
eldest  forty-six.  The  number  less  than  20  years  of  age  was  ten,  from  20  to 
30  years  thirty-two,  from  30  to  40  years  thirteen,  from  40  to  50  years  two. 

In  regard  to  rank,  fourteen  were  officers;  viz.,  five  lieutenants,  seven 
sergeants,  and  two  corporals  ;  the  remaining  forty-three  were  privates. 

Pygemia  is  recorded  as  a  cause  of  death  in  eight  cases. 

Chloroform  was  used  in  all  the  cases.  * 

Of  the  fifty -seven  cases  of  amputations,  twenty-five  were  done  September 
lYth,  the  day  on  which  the  battle  occurred,  most  of  them  at  night,  only 
one  case  proved  fatal. 

Sept.  18,  twenty -four  amputations  were  made,  three  of  which  were  fatal. 

Sept.  19,  four  amputations,  two  fatal  cases. 

Sept.  20,  one  amputation  ;  doing  well. 

Sept.  22,  23,  and  29,  one  amputation  each  day,  the  first  two  fatal,  and 
the  third  probably  so. 

It  is  proper  to  state,  that  great  care  was  taken  to  obtain  and  include  the 
histories  of  all  the  fatal  cases  that  had  occurred  from  amputations  after  ' 
the  battle,  at  all  the  houses  where  the  statistics  were  collected.  The  writer 
was  particular  in  his  personal  examination  of  all  the  stumps,  and  in  his 
observations  as  to  the  vital  condition  of  the  patients,  and  in  all  doubtful 
cases  to  consult  with  the  surgeons  in  charge  in  reference  to  the  prognosis. 
Wherever,  in  the  remarks  included  in  the  tables,  the  patient  is  said  to  be 
"  doing  well,"  it  is  confidently  believed  that  he  will  recover. 

It  may  be  urged,  as  an  evidence  of  the  entire  want  of  value  of  the  above 
tables,  that  the  facts  were  collected  too  early  in  the  history  of  the  cases, 
that  many  cases,  from  a  variety  of  causes,  would  terminate  fatally  after  the 
sixteenth  day  from  the  date  of  operation.  The  writer  is  aware  of  this  ob- 
jection, but  being  unable  to  remain  longer  with  the  patients,  he  was  com- 
pelled to  prematurely  collect  the  materials  to  rescue  the  facts  from  entire 
loss.  He  thinks,  however,  that  at  the  end  of  sixteen  days  the  tendency  to 
recovery  or  death  ought  to  be  quite  definitely  determined,  but  his  chief 
apology  is,  as  elsewhere  mentioned,  that  the  materials  were  arranged  and 
published  with  a  view  to  illustrate  a  uniform  plan  of  reports,  rather  than 
for  their  intrinsic  value. 


Art.  IV. — On  Trismus  Nascentium.    By  Greensville  Dowell,  M.  D., 
Columbia,  Brazoria  County,  Texas. 

My  attention  was  first  drawn  to  the  pathology  of  trismus  nascentium, 
by  the  paper  of  Dr.  Sims,  formerly  of  Montgomery,  Ala.,  now  of  New 
York,  published  in  this  journal.  (See  Nos.  for  April,  1846,  July  and  Oct. 
1848.)  That  writer  adduced  a  number  of  cases  to  show  that  the  disease 
resulted  from  compression  of  the  brain  caused  by  the  overlapping  of  the 


52 


Do  well,  Trismus  Nascentium. 


[Jan. 


bones  of  the  cranium.  An  opportunity  was  soon  after  afforded  me,  in  Fanola 
County,  Miss.,  where  I  then  practised,  of  testing  the  correctness  of  these 
views.  I  was  called  to  a  case  on  the  plantation  of  Mrs.  H.,  in  which  there 
was  evidently  displacement  of  the  occiput,  and  I  immediately  determined  to 
try  Dr.  Sims's  practice.  I  placed  the  child  on  its  side  on  a  pillow,  and 
changed  it  from  one  side  to  the  other.  I  directed  its  bowels  to  be  moved  with 
sweet  oil,  and  in  a  few  hours  the  spasms  subsided,  the  child  could  nurse,  and 
in  a  very  short  time  it  was  quite  well,  and  is,  I  believe,  now  living.  This 
was  the  first  case  of  the  disease  I  had  ever  seen  recover ;  and  Mrs.  H.,  who 
was  a  very  intelligent  lady,  the  widow  of  a  physician  who  had  practised 
many  years  in  Georgia,  told  me  that  this  was  the  first  case  she  had  ever  seen 
recover,  and  that  she  had  lost  many  negro  children  with  the  disease,  both  in 
Georgia  and  Mississippi.  The  disease  was  quite  common  amongst  the  blacks 
in  Panola  County,  but  I  never  saw  a  case  amongst  the  whites  while  I  prac- 
tised in  that  section.  The  success  in  this  case  quite  elated  me.  In  the  next 
I  was  called  to  I  adopted  the  same  treatment,  but  could  not  discover  that 
there  was  any  displacement  of  the  occiput  or  parietal  bones.  The  treatment 
.  failed,  and  I  made  a  post-mortem  examination,  but  could  not  discover  any 
organic  or  mechanical  injury  about  the  head.  The  umbilicus  was  well  healed, 
but  there  was  dark  blood  in  the  umbilical  vein,  and  a  yellowness  around 
the  navel.  The  liver  was  congested,  and  the  gall-bladder  filled  with  dark 
thick  bile.    The  bowels  were  empty,  and  apparently  entirely  healthy. 

This  case  led  me  to  think  that  the  primary  cause  of  the  disease  was  in 
the  umbilicus,  and  brought  on  by  congestion  of  the  liver,  induced  by  coagu- 
lation of  the  blood  in  the  umbilical  vein.  Several  times  since  I  have  found 
these  changes  in  post-mortem  examinations,  and  am  free  to  declare  that 
the  majority  of  the  cases  I  have  met  with  have  been  of  this  character.  The 
only  case  in  a  white  child  I  have  seen  in  this  county  was  of  this  character, 
and  as  the  case  is  an  interesting  one  I  shall  give  the  particulars  of  it. 

Mrs.  S.,  the  wife  of  an  overseer,  was  taken  very  suddenly  in  labour,  and 
as  I  lived  some  nine  miles  distant,  they  sent  for  a  very  intelligent  negro  mid- 
wife, but  the  child  was  born  before  she  got  there ;  the  placenta  was  thrown 
off  with  the  child.  She  cut  the  cord  about  six  inches  from  the  umbilicus, 
and  wrapped  it  with  a  tape  string  up  to  the  umbilicus.  The  umbilical  cord 
came  off  at  the  usual  time.  About  the  eighth  day  the  child  refused  to 
nurse,  and  spasms  came  on,  and  with  each  spasm  there  was  hemorrhage 
from  the  umbilicus.  They  sent  immediately  for  me.  I  tried  to  stop  the 
hemorrhage  with  nitrate  of  silver,  but  to  no  effect.  I  then  put  two  needles 
through  the  base  of  the  umbilicus,  and  a  ligature  beneath  them.  This 
stopped  the  hemorrhage  for  a  while,  but  it  returned  in  about  four  or  five 
hours.  By  tightening  the  ligatures  the  hemorrhage  was  kept  down,  but 
the  spasms  continued  to  return,  and  finally  the  child  starved  to  death, 
though  the  spasms  were  sufficient  to  kill  it. 

Other  cases  which  have  come  under  my  observation  I  have  thought  were 


1863.] 


Do  well,  Trismus  Nascentium. 


53 


brought  on  from  the  irritation  of  the  meconium  ;  the  children  of  this  class 
not  having  proper  attention.  The  bowels  in  these  became  distended,  and 
when  they  were  moved  by  medicine,  the  discharges  were  frequent  and  too 
watery.  Finally,  the  child  would  not  suck,  and  spasms  followed.  Another 
cause,  it  appears  to  me,  has  been  the  neglect,  on  the  part  of  the  nurses,  of 
cleansing  the  body  and  head  of  the  child  at  birth.  This  becomes  a  source 
of  irritation,  ultimately  producing  congestion  of  the  brain  and  spasms. 
Some  of  our  physicians  think  that  there  is»a  hereditary  or  constitutional 
tendency  in  the  children  of  some  mothers  to  take  on  this  disease.  We 
know  that  some  mothers  lose  all  their  children  with  it.  So  much  imbued 
are  many  of  our  planters  with  this  notion,  that  often  they  tell  the  midwife 
if  they  can  save  such  children  they  may  have  them.  All  such  cases  that 
have  come  under  my  care  have  been  saved  by  the  plan  I  shall  presently 
describe  for  their  treatment.  With  all  my  past  experience  and  observation, 
I  have  come  to  the  following  conclusion  : — 

1st.  That  the  disease  is  produced  most  frequently  from  improper  manage- 
ment of  the  cord,  and  congestion  of  the  blood  in  the  umbilical  vein  ;  from 
this  vein  congestion  spreads  to  the  liver,  and  it  becomes  swollen  and 
filled  with  dark  blood,  and  the  secretion  of  bile  is  entirely  arrested. 

2d.  The  next  most  frequent  cause  is  the  displacement  of  the  occipital 
bones  in  parturition.  We  may  always  look  for  this  cause  in  protracted 
labours. 

3d.  The  retention  of  the  meconium,  and  want  of  proper  cleansing  of  the 
skin  when  the  child  is  first  dressed. 

4th.  And  lastly,  it  may  be  produced  from  any  cause  that  will  produce 
tetanus  in  old  persons.  Cold,  exposure  to  drafts  of  cold  air ;  foul  odours, 
such  as  emanate  from  old  bedclothes,  saturated  with  urine  and  besmeared 
with  feces,  which  are  often  to  be  found  in  our  negro  cabins,  when  the  mas- 
ters are  not  particular  to  make  the  tenants  wash  and  clean  out  their  houses. 
Negroes  often  go  to  sleep  and  let  their  children  fall  or  overlay  them,  which 
also  brings  on  the  disease.  I  believe  I  have  seen  it  produced  from  all  these 
causes. 

The  symptoms  vary  but  little  in  this  disease.  Let  it  be  produced  from 
any  one  of  these  causes,  the  first  symptom  is  a  want  of  power  in  the  child 
to  nurse,  or  a  disinclination,  most  generally ;  they  will  feed  from  a  spoon, 
when  they  cannot  suck. 

It  is  almost  sure  to  come  on  between  the  fifth  and  twelfth  day  after  birth, 
generally  about  the  ninth  day ;  though  it  may  occur  any  time  within  six 
months,  and  some  think  even  within  two  years.  I  have  not  known  any  to 
occur  at  so  late  a  period,  and  but  one  or  two  cases  after  thirty  days.  I 
always  consider  the  child  safe  from  the  effects  of  mismanagement  of  the 
umbilical  cord,  if  they  live  three  weeks  (Dr.  Morris  says  fifteen  days),  never 
having  seen  a  case  that  appeared  to  me  to  have  originated  after  that  time, 
from  this  cause.    Those  that  occur  from  displacement  of  the  occiput  may 


54 


Do  well,  Trismus  Nascentium. 


[Jan. 


occur  at  any  time  within  two  years,  as  many  negro  children  are  left  for  three 
or  four  hours  in  one  position,  generally  on  the  back.  Often  all  the  hair  is 
rubbed  off,  and  the  body  is  confined  in  a  small  cradle  with  scarcely  room  to 
turn  over.  These  boxes  are  very  objectionable,  and  I  always  endeavour  to 
prevail  upon  the  parties  to  entirely  banish  them.  I  much  prefer  that  the 
child  should  be  laid  on  the  floor,  with  only  a  blanket,  than  placed  in  the 
cradles  in  use  by  most  of  our  negroes. 

The  spasms  are  various;  sometimes  only  partial  and  scarcely  perceptible, 
and  at  other  times  general  and  very  severe.  The  abdominal  muscles  are 
contracted  in  nearly  all  cases  during  the  spasms ;  in  some  cases  one  side 
alone  appeared  to  be  affected,  and  the  muscles  of  that  side  of  the  face  drew 
the  mouth  to  one  side  in  a  most  frightful  manner.  In  most  cases  the  hands 
are  clenched  all  the  time.  The  patients  cry  but  little,  but  appear  to  suffer 
much  when  moved  or  handled. 

Fever  is  occasionally,  though  not  usually  present ;  its  occurrence  indeed 
is  the  exception  to  the  general  rule.  The  tongue  is  generally  coated  with 
a  white  or  brown  fur. 

When  called  to  one  of  these  cases,  my  first  object  is  to  ascertain  from 
which  of  the  causes  enumerated  the  attack  had  originated.  I  begin  my  in- 
vestigations with  the  head,  as  described  by  Dr.  Sims,  by  examining  all  the 
sutures,  to  see  if  there  is  any  overlapping,  or  if  any  of  the  bones  are 
movable.  If  pressure  on  any  one  of  them  produces  uneasiness  or  spasms, 
I  press  gently  on  the  fontanelle,  and  if  the  disease  is  produced  from  the 
misplacement  of  any  of  the  bones  of  the  cranium,  it  will  give  the  patient 
pain,  and  often  produce  a  spasm.  I  press  my  finger  gently  on  all  the 
sutures,  to  see  if  the  two  edges  meet,  and  that  the  head  is  smooth,  and  no 
thrombus  or  any  perceptible  misplacement.  Should  there  be  any,  I  imme- 
diately place  them  according  to  Dr.  Sims' s  plan — on  a  soft  bed :  if  the 
occiput  is  at  fault,  on  the  side ;  if  the  parietal,  on  the  bach.  I  direct  them 
to  be  held  to  the  breast  on  a  pillow ;  do  not  allow  the  arm  to  be  put 
under  their  head,  as  they  are  usually  nursed  ;  order  them  changed  at  least 
every  two  or  three  hours,  whether  asleep  or  awake.  I  have  the  bowels 
moved  with  sweet  oil,  and  have  them  fed  with  a  spoon  sufficiently  only 
to  keep  up  their  strength. 

In  those  cases  occurring  from  the  umbilicus,  I  would  rub  the  abdomen 
with  an  ointment  of  the  iodide  of  mercury,  gr.  x  to  3j  of  lard,  and  give  from 
one  to  five  grains  of  calomel  internally.  I  frequently  have  tried  to  control 
the  spasms  with  a  watery  solution  of  assafcetida,  made  by  pouring  warm 
water  on  chipped  assafcetida.  This  seemed  to  me  to  do  good  in  some 
instances,  and  had  a  better  effect  than  anything  I  have  yet  tried.  The 
preparations  of  opium  do  no  good ;  but  stupefy  the  patient,  and  hasten  its 
death.  I  use  warm  mustard  baths  in  all  cases,  and  nearly  always  with 
present  relief  to  the  spasms.  I  have  blistered  the  umbilicus,  but  with  no 
benefit. 


1863.]  Do  well,  Trismus  Nascentium.  55 


Where  the  disease  originates  from  any  other  cause,  it  should  be  found  out 
and  removed.  If  the  skin  is  not  entirely  clean  and  all  the  dandruff  gotten 
out  of  the  hair,  this  should  be  done  immediately,  and  the  bowels  moved 
with  sweet  oil  or  the  calomel  as  in  the  last  case.  When  they  have  fever,  I 
never  fail  to  give  quinia,  and  generally  with  improvement  of  symptoms.  I 
have  cured  a  well-marked  sore  with  calomel  followed  by  quinia  and  assa- 
foetida  and  mustard  bath.  I  have  several  times  blistered  the  spine  ;  but  to 
no  effect.  In  nearly  all  cases  I  have  used  some  liniment  to  the  spine — 
generally  sweet  oil,  ammonia,  and  turpentine — not  strong  enough  to  blis- 
ter, as  this  interferes  with  the  mustard  bath,  in  which  I  have  more  confi- 
dence. 

It  is  the  general  opinion  of  our  physicians  that  after  the  spasms  com- 
mence nothing  can  be  done,  and  in  that  opinion  I  must  concur.  I  have 
seen  but  three  cases  recover  under  any  and  all  plans  hitherto  tried — the  case 
related,  and  two  others  cured  by  the  plan  suggested  above.  I  have  relieved 
many  cases,  after  they  had  refused  to  suck,  by  this  plan,  and  I  can  speak 
of  its  efficiency  with  confidence.  Our  physicians  are  not  often  called  until 
the  case  is  hopeless,  but  I  have  lived  nearly  all  my  professional  life  on  a 
plantation  where  there  were  from  thirty  to  one  hundred  and  fifty  negroes, 
who  were  especially  under  my  care,  and  it  was  my  instruction  to  the  lying- 
in  women,  as  soon  as  their  children  would  not  nurse,  to  bring  them  to  me. 
In  that  way  I  have  cured  many.  Some  with  slight  twitchings  of  the 
muscles  have  recovered  without  any  trouble,  by  being  put  in  a  mustard 
bath,  washed  clean,  and  put  in  a  clean  and  well  ventilated  cabin.  I  have 
tried  ether  and  chloroform,  but  with  no  success. 

Our  main  reliance  is  in  prevention.  Nearly  every  physician  has  his 
own  method  of  treatment,  and  I  will  give  mine,  which  I  respectfully  submit 
as  appearing  to  me  to  be  the  most  efficacious. 

My  first  object  is  to  have  the  house  of  the  patient  and  all  the  bedclothes 
clean;  and  when  this  has  not  been  previously  attended  to,  I  have  it  done 
as  soon  as  convenient.  Not  more  than  four  persons  should  be  allowed  to 
be  in  a  cabin,  and  I  would  prefer  only  the  nurse  and  husband  to  be  there. 
As  soon  as  the  child  is  born  and  it  has  breathed,  I  tie  two  ligatures 
around  the  cord,  the  first  at  such  a  distance  from  the  umbilicus — say  about 
half  an  inch — as  to  give  me  a  chance,  should  I  not  tie  it  tight  enough,  to 
put  another  between  this  and  the  umbilicus.  The  other  ligature  I  put 
about  an  inch  from  the  first,  and  cut  the  cord  between  them. 

It  has  been  the  custom  with  our  negro  midwives,  especially  the  Africans, 
to  tie  the  cord  about  four  or  five  inches  long,  and  to  coil  it  around  on  the 
abdomen.  Most  of  them  cut  it  about  two  inches  long,  so  far  as  I  know. 
And  here  I  will  mention  a  fact  told  me  by  Dr.  S.  A.  Towsy  : — 

Several  years  ago  he  was  employed  to  attend  to  the  plantation  of 
negroes  now  owned  by  Col.  S.,  of  this  county,  who  are  mostly  Africans 
brought  to  this  county  before  annexation.    He  had  been  told  that  they 


56       Walter,  Removal  of  Foreign  Bodies  from  Air-Passages.  [Jau. 

lost  all  of  their  young  children  with  this  disease,  and  that  the  owner's  in- 
tention was  to  see  if  he  could  not  save  them.  That  year  there  were  born 
on  the  place  thirteen  children,  and  he  attended  eleven.  The  eleven  he 
attended  lived  and  did  well ;  the  other  two  died  with  this  disease.  He  saw 
one  of  them  with  the  disease,  and,  upon  examination  he  found  that  the 
cord  had  been  left  some  ten  or  eleven  inches  long,  and  was  wound  around 
in  a  coil  upon  the  abdomen.  There  was  tenderness  over  the  liver  and 
bowels,  indicating  that  the  disease  originated  from  that  source.  He  in- 
quired of  the  midwife  if  that  was  the  way  she  dressed  all  her  children,  and 
she  said  it  was,  and  that  they  all  died  in  the  same  way,  and  about  the  ninth 
day. 

After  cutting  the  cord,  I  have  the  child  put  in  a  tub  of  warm  water, 
washed  perfectly  clean,  head  and  body,  and  then  I  cut  out  a  hole  in  a  piece 
of  soft  linen  and  wrap  the  end  of  the  cord  in  burnt  cotton,  and  fold  the 
linen  over  the  cord  and  cotton,  and  then  put  the  middle  of  the  bandage 
over  this,  and  pin  it  on  the  back.  I  have  the  bandage  tight  enough  to 
prevent  its  slipping  or  moving  abou^  but  not  to  give  pain.  In  this  situa- 
tion I  recommend  it  to  be  kept  for  five  days,  noticing  the  bandage  to  see  if 
there  is  any  hemorrhage.  I  then  direct  the  child  to  be  carefully  nursed, 
and  not  to  be  left  too  long  in  one  situation  ;  the  head  to  be  kept  cool,  and 
without  any  caps. 

Under  this  plan  I  have  not  lost  a  single  case  that  I  have  had  special  charge 
of.  This  is  the  experience  of  all  those  who  have  followed  this  plan  or  a 
similar  one.  A  practitioner  of  our  county  gives  half  grain  doses  of  calo- 
mel from  birth,  twice  or  three  times  a  day,  for  nine  days.  This  I  think 
very  objectionable,  and,  though  calomel  is  good,  where  there  is  fever  and 
a  derangement  of  the  digestive  organs  it  should  be  given  with  judgment 
and  caution.  But  I  think  this  plan  itself  would  often  bring  on  the  dis- 
ease ;  and  as  the  disease  is  more  common  in  his  neighbourhood  than  in 
any  other  portion  of  the  county,  I  am  inclined  to  believe  it  is  from  this 
cause.  It  has  not  been  so  frequent  in  the  last  two  years  as  formerly.  The 
obtaining  of  physicians  in  such  cases  more  than  before,  and  the  improve- 
ment in  their  management,  I  think  is  the  reason. 


Art.  V. —  Tracheotomy  for  the  Removal  of  Foreign  Bodies  from  the  Air- 
Passages.    With  Cases.    By  A.  Gr.  Walter,  Surgeon,  Pittsburg,  Pa. 

Surgical  operations,  so  dreaded  in  general,  lose  much  of  their  terrors  in 
>ases  where  a  foreign  body  having  entered  the  air-passages,  strangulation  is 
imminent  and  delay  is  manifestly  fraught  with  danger.  JSTot  only  is  con- 
sent to  operative  measures  readily  obtained,  but  often  urgently  demanded 
by  the  sufferer. 


1863.]    Walter,  Removal  of  Foreign  Bodies  from  Air-Passages.  || 


Tracheotomy  though  comparatively  simple  in  its  performance,  and 
generally  harmless  in  its  consequences  is  not  only  too  often  neglected,  but 
even  too  long  delayed  for  the  safety  of  the  patient  and  the  credit  of  the 
practitioner.  Although  the  advance  of  modern  surgical  pathology  has 
considerably  lessened  the  frequency  of  operations,[yet,  with  regard  to  foreign 
bodies  impacted  in  the  air-tubes,  the  rule  must  ever  be  that  the  knife  should 
be  early  used  as  the  most  certain  means  of  relief.  The  following  cases  but 
confirm  the  soundness  of  this  time  honoured  practice. 

Case  1.  John  McCarty,  of  Pittsburg,  aged  six  years,  of  good  constitu- 
tion, while  playing  with  a  pebble  in  his  mouth,  swallowed  it  as  he  sup- 
posed ;  violent  convulsive  efforts  of  coughing  immediately  followed. 
Emetics  and  purgatives  were  resorted  to  in  order  to  dislodge  the  offending 
body  from  the  stomach.  The  idea  that  it  had  entered  the  trachea  being  * 
ridiculed  by  the  medical  attendant,  and  as  some  cessation  of  the  violent  fits 
of  coughing  occurred  after  some  days,  the  parents  were  disposed  to  believe 
that  the  stone  would  eventually  be  removed  by  the  natural  channel.  The 
respite,  however,  was  of  but  short  duration  ;  paroxysms  of  coughing  again 
became  frequent,  threatening  suffocation,  and  the  boy  rapidly  lost  flesh  and 
strength  from  fever  and  profuse  expectoration.  Three  weeks  after  the 
accident  had  occurred,  I  was  requested  to  see  him.  On  examination  of  the 
chest  by  the  stethoscope  no  unusual  sound  was  heard  in  the  right  lung, 
while  in  the  left  loud  mucous  rales  were  present ;  during  a  fit  of  coughing 
a  solid  body  was  distinctly  heard  to  move  up  and  down  ;  when  it  reached 
the  larynx  suffocation  became  imminent ;  on  its  descent  it  appeared  to  enter 
the  right  bronchus  ;  there  was  hectic  with  night-sweats,  continued  restless-  . 
ness  and  disturbed  sleep.  Convinced  of  the  presence  of  a  foreign  body  in 
the  windpipe,  I  urged  its  immediate  removal  by  operation ;  to  this,  with 
some  difficulty,  the  parents  consented,  as  they  were  led  to  believe  that  under 
no  circumstances  could  anything  by  accident  enter  the  larynx  guarded  as 
it  was  by  the  epiglottis  as  a  safety  valve.  Having  removed  this  false 
impression,  I  had  recourse  to  Sir  Benjamin  Brodie's  plan  of  inverting  the 
body  of  the  patient,  but  without  benefit,  the  stone  being  too  large  to  pass 
the  highly  irritated  glottis.  On  April  6th,  1854,  assisted  by  Dr.  Gucnote, 
the  trachea  was  opened  to  the  extent  of  three-fourths  of  an  inch  in  the 
median  line  below  the  crico-thyroid  cartilage,  the  skin  and  cellular  tissue 
having  been  previously  divided,  and  the  free  bleeding  having  been  arrested  by 
cold  and  compression  (no  ligatures  being  required).  On  the  interior  of  the 
windpipe  being  opened  a  violent  paroxysm  of  coughing  ensued,  throwing 
up  a  large  quantity  of  ropy  mucus,  closing  the  aperture  and  threatening 
suffocation  ;  this  being  speedily  removed  and  the  lips  of  the  wound  being 
held  asunder,  mucus  was  freely  ejected  by  coughing  and  with  it  an  oval- 
shaped  pebble  of  the  size  of  a  large  bean  was  forcibly  projected  through  the 
aperture.  The  relief  was  complete,  and  the  paroxysm  of  coughing  ceased. 
The  lips  of  the  wound  having  been  cleansed  of  blood  and  mucus  were 
approximated  and  retained  by  adhesive  plaster,  with  the  exception  of  its 
lower  angle,  which  was  left  open  to  allow  a  free  exit  to  secretions  from  the 
trachea.  Considerable  febrile  reaction  following,  a  vein  was  opened  in  the 
arm  dfting  the  evening;  with  gentle  antiphlogistics  and  proper  regimen  the 
case  progressed  favourably.  The  fever  subsided,  the  cough  ceased,  sleep 
soon  became  natural  and  appetite  returned ;  on  the  4th  day  the  patient  left 
his  bed,  by  the  10th  day  the  wound  had  perfectly  closed. 


58      Walter,  Removal  of  Foreign  Bodies  from  Air-Passages.  [Jan. 

Case  2.  Chas.  Fichtar,  of  Alleghany  City,  aged  16  years,  was,  while 
eating  chestnuts,  suddenly  seized  with  a  paroxysm  of  coughing  and  hoarse- 
ness. Suspecting  that  a  portion  of  the  nut  was  lodged  in  his  throat,  a  pro- 
bang  was  passed  into  the  oesophagus  by  a  practitioner.  Relief  was  not 
obtained  ;  various  remedies  were  next  prescribed  to  allay  the  cough,  but 
without  avail ;  the  distressing  symptoms  still  continued,  the  cause  not  being 
recognized.  Fever,  with  loss  of  appetite  and  disturbed  sleep,  soon  became 
superadded.  It  was  now  evident  from  the  history  of  his  case  and  continu- 
ance of  distress  that  a  part  of  the  nut  or  shell  had  entered  the  larynx ;  the 
patient  and  his  friends  agreeing  in  our  opinion  readily  consented  to  the 
operation.  On  July  12th,  1854,  the  treachea  was  opened  to  the  extent  of  an 
inch,  all  bleeding  having  been  previously  arrested.  As  usual  on  the  sudden 
entrance  of  air  through  a  wound  in  the  trachea,  violent  fits  of  coughing 
ensued,  arresting  momentarily  examination  of  the  interior  of  the  larynx  by 
forceps  or  probe.  Every  attempt  to  introduce  either  increased  the  spasmodic 
efforts  at  coughing.  After  some  minutes'  rest,  the  head  of  the  patient  being 
raised  and  the  lips  of  the  tracheal  wound  being  held  apart  by  blunt  hooks, 
a  small  bent  polypus  forceps  was  gently  introduced  upwards  into  the  larynx, 
from  whence,  after  much  careful  exploration,  half  the  shell  of  a  chestnut 
was  removed  with  instant  relief,  the  fits  of  coughing  immediately  ceasing. 
The  edges  of  the  wound  were  next  brought  together  and  retained  by  adhe- 
sive plaster,  over  which  water  dressing  was  applied.  During  the  evening  a 
free  bleeding  from  the  arm  controlled  the  vascular  excitement  which  ensued, 
after  which  the  case  progressed  favourably,  the  hoarseness  soon  subsided, 
and  by  the  end  of  the  2d  week  the  wound  had  closed. 

Case  3.  Peter  Frazer,  of  Pittsburg,  aged  25  years,  a  labourer,  was,  while 
taking  some  meat  soup,  almost  suffocated,  a  piece  of  bone  having  entered 
the  larynx.  The  cough,  as  usual,  was  very  distressing,  accompanied  with 
hoarseness  and  the  sensation  of  a  foreign  body  sticking  in  the  throat. 
Emetics  were  tried ;  the  probang  passed  into  the  esophagus  repeatedly, 
and  various  remedies  prescribed  by  his  physician,  extending  over  a  period 
of  two  weeks ;  when,  finding  no  relief,  he  sought  admission  into  my  hospi- 
tal. There  was  then  a  teazing,  laryngeal  cough,  with  fever,  restlessness, 
and  frequent  feeling  of  strangulation.  Relief  being  urgently  demanded, 
the  trachea  was  opened  without  difficulty  on  the  16th  of  December,  1854, 
and  with  little  loss  of  blood;  a  probe  detected  the  solid  body  in  the  larynx, 
but  the  attempt  to  seize  it  with  a  bent  polypus  forceps  was  repeatedly  frus- 
trated by  the  violent  efforts  of  coughing,  which  the  introduction  of  the 
instrument  excited.  After  some  delay  it  was  grasped  and  removed.  It 
proved  to  be  a  sharp-pointed  bone,  three-quarters  of  an  inch  long,  and  one- 
sixteenth  inch  broad,  which  had  lodged  obliquely  across  the  larynx.  The 
relief  to  the  patient  was  immediate.  The  wound  was  brought  together  by 
adhesive  plaster,  over  which  water  dressing  was  applied.  Venesection  was 
had  recourse  to  in  the  evening  to  allay  inflammatory  fever,  after  which  no 
untoward  symptom  occurred ;  the  cough  and  hoarseness  subsided,  and  in 
sixteen  days  the  wound  had  closed. 

Case  4.  Jacob  Steel,  aged  six  years,  of  Alleghany,  City,  was  suddenly 
seized  with  violent  fits  of  coughing,  threatening  suffocation,  but  unable  to 
tell  his  parents  what  had  happened,  it  was  difficult  to  ascertain  the  cause. 
It  was,  however,  discovered  that  a  piece  of  slate  pencil  had  by  accident 
lodged  in  the  windpipe.    The  probang,  emetics,  and  other  remedies  were 


1863.]    Walter,  Removal  of  Foreign  Bodies  from  Air-Passages.  59 

resorted  to  without  relief  for  some  days.  On  the  fifth  day  after  the  acci- 
dent I  was  requested  to  see  him.  By  the  aid  of  the  stethoscope,  a  foreign 
body  was  distinctly  heard  to  move  up  and  down  during  the  efforts  of 
coughing.  On  the  27th  of  April,  1855,  assisted  by  Dr.  Lusk,  I  opened 
the  trachea  to  the  extent  of  three-quarters  of  an  inch.  The  struggles  of 
the  patient,  the  convulsive  fits  of  coughing,  and  profuse  flow  of  mucus 
from  the  wound,  caused  some  delay ;  but  after  comparative  quiet  was  re- 
stored, the  patient  was  raised  to  a  half-sitting  posture,  the  wound  cleansed 
and  its  edges  held  apart  by  blunt  hooks,  when  a  sudden  fit  of  coughing 
brought  the  pencil  into  view;  it  was  immediately  seized  and  removed  with 
safety.  The  wound  was  dressed  as  usual,  an  outlet  being  left  at  its  lower 
angle ;  water  dressings  and  antiphlogistic  regimen  constituted  the  treatment. 
In  six  days  the  patient  left  his  bed.    In  two  weeks  the  wound  had  closed. 

Case  5.  Michel  Fritz,  aged  60  years,  of  Alleghany  City,  a  cabinet- 
maker, of  low  stature,  strong  frame,  large  muscular  development,  and  short 
neck,  applied  on  account  of  a  distressing  cough  and  hoarseness  of  four 
weeks'  standing.  The  history  of  his  case  was  as  follows  :  While  playing 
with  his  child  seated  on  his  knee,  he  threw  a  copper  cent  repeatedly  into 
his  mouth,  which  suddenly  disappeared,  causing  a  feeling  of  choking,  with 
violent  coughing.  Supposing  the  cent  was  resting  in  the  throat,  he  ate 
bread  and  drank  water,  without,  however,  at  all  relieving  the  paroxysms  of 
coughing ;  and  though  the  cough  brought  on  free  vomiting,  he  became 
hoarse  and  unable  to  speak  above  a  whisper.  After  some  days,  the  vio- 
lence o*f  the  cough  subsided,  as  if  he  could  not  cough  for  want  of  breath. 
He  feels  as  if  the  larynx  was  obstructed  with  something,  and  soreness  is 
complained  of  in  the  part  on  pressure.  His  voice  is  feeble  and  croupy,  and 
respiration  oppressed  but  not  accelerated.  Respiratory  murmur  feeble,- 
percussion  normal,  pulse  80.  Feels  chills  and  flashes  of  heat,  sleeps  badly, 
prefers  the  half-sitting  posture  in  bed  ;  is  thirsty,  has  no  appetite,  and  suf- 
fers from  night-sweats.  No  mucous  rales  in  the  bronchia,  nor  expectora- 
tion. On  passing  a  probang  with  a  small  piece  of  sponge  attached  into 
the  esophagus,  no  difficulty  was  experienced  ;  but  on  withdrawing,  it 
seemed  to  be  arrested,  behind  the  larynx,  by  some  projecting  body,  which 
offered  considerable  obstruction  to  its  removal.  It  was  difficult  to  persuade 
him  that  the  cent  had  found  its  way  into  the  larynx;  fancied  it  had  passed  to 
the  stomach,  and  would  be  ultimately  expelled  by  the  bowels;  has  been  told 
so  by  his  medical  attendant,  and  the  hoarseness  and  cough  treated  as  a  cold; 
but  as  no  mitigation  of  his  distress  has  been  obtained  by  such  treatment, 
his  friends,  with  better  judgment  than  his  physician,  insist  that  it  must  be 
in  his  windpipe,  and  urge  him  to  seek  admission  into  our  hospital.  I  felt 
little  difficulty  in  deciding,  from  the  history  of  the  case,  from  the  obstruction 
in  withdrawing  the  probang  and  the  other  general  symptoms,  that  his  was 
a  proper  case  for  tracheotomy.  Accordingly,  on  the  16th  of  March,  1856, 
four  weeks  after  the  occurrence  of  the  accident,  the  operation  was  per- 
formed in  presence  of  Doctors  Hageman  and  Pillichody.  The  neck  being 
short  and  plump,  the  integuments  and  deep-seated  parts  gorged  with  blood, 
much  difficulty  was  anticipated  during  the  operation.  The  patient  being 
placed  in  a  half-sitting  position,  with  the  chin  well  raised,  an  incision  was 
made  from  below  the  cricoid  cartilage  to  the  sternum,  in  the  median  line, 
through  the  skin  and  cellular  tissue,  which  were  unusually  loaded  with  fat. 
The  edges  of  the  incision  being  held  apart,  the  sterno-hyoid  and  sterno- 
thyroid muscles  were  separated  from  their  fellows  by  slight  touches  of  the 


60       Walter,  Removal  of  Foreign  Bodies  from  Air-Passages.  [Jan. 


knife  and  a  probe.  Having  arrested  the  profuse  bleeding  by  cold  and  com- 
pression, and  removed  the  thick  layers  of  fat  found  above  and  beneath  the 
deep  fascia  of  the  neck,  the  arteria  thyroideaima  was  seen  running  in  front 
of  the  trachea,  a  small  branch  of  which  having  been  cut  had  to  be  liga- 
tured. From  the  shortness  of  the  neck  and  the  quantity  of  fat,  the  depth 
of  the  wound  was  nearly  one  and  a  half  inches.  The  trachea  being  thus  ex- 
posed, the  tissue  immediately  covering  it  was  removed  by  a  probe,  the  artery 
carefully  held  aside,  and  the  trachea  was  then  pierced  by  the  knife,  and 
four  of  its  rings  divided  in  an  upward  direction.  They  were  found  rigid, 
from  commencing  ossification.  Immediately  on  opening  the  trachea,  violent 
coughing  ensued  with  profuse  bleeding,  both  from  the  wound  and  from  the 
congested  mucous  membrane.  The  patient  had  to  be  raised,  the  edges  of 
the  wound  held  apart  to  allow  free  egress  to  the  blood  from  the  trachea, 
and  the  breathing  to  become  quiet.  This  being  accomplished,  the  trachea 
was  sounded  by  a  flexible  urethral  sound  upwards  and  downwards,  which 
provoked  renewed  fits  of  coughing,  with  bleeding  and  a  feeling  of  strangu- 
lation. Respite  from  coughing  being  again  obtained,  the  exploration  of 
the  larynx  was  made  with  a  bent  polypus  forceps,  when  the  cent  was  de- 
tected in  the  larynx,  the  edge  forwards,  tightly  enclosed  by  the  swollen  mucous 
membrane.  On  being  seized,  the  forceps  slipped,  though  moving  it  some- 
what from  its  situation.  At  this  moment  the  patient  was  well  nigh  stran- 
gled. After  a  short  pause,  in  a  further  attempt,  I  succeeded  in  grasping  the 
cent  firmly  and  removing  it,  but  not  without  considerable  force.  I,  how- 
ever, held  it  preferable  to  bring  it  down  and  extract  it  by  the  tracheal 
wound,  notwithstanding  the  force  required,  rather  than  attempt  to  force  it 
upwards  by  the  glottis.  Such  a  course  being  likely  to  lacerate  the  chordae 
vocales  glottis  or  mucous  membrane,  or  even  rupture  the  larynx.  The 
patient,  now  finding  himself  relieved,  was  much  rejoiced,  and,  looking  at 
the  offending  body,  exclaimed,  that  it  was  a  costly  and  dearly-bought  cent 
to  him.  A  pledget  of  lint  being  laid  in  the  lower  angle  of  the  wound,  to 
favour  the  escape  of  secretions  from  the  trachea,  the  edges  were  approxi- 
mated and  retained  by  adhesive  plaster.  He  was  placed  on  his  side  in  bed, 
aud  water  dressing  applied  ;  his  cough  continued  teazing  for  some  time, 
but  gradually  subsided  ;  his  respiration  becoming  more  free,  and  his  coun- 
tenance calm.  In  the  evening,  his  pulse  becoming  full,  a  free  bleeding  from 
the  arm  with  strict  antiphlogistic  treatment  was  prescribed.  On  the  follow- 
ing day,  a  further  venesection  was  found  necessary,  the  pulse  being  full  and 
rapid ;  pain  in  the  larynx,  with  sonorous  breathing,  the  voice  hoarse  from 
the  swollen  condition  of  the  mucous  membrane ;  the  blood  was  highly 
inflammatory.  Ordered  a  continuance  of  the  antiphlogistic  treatment.  The 
case  from  this  forward  progressed  favourably ;  the  voice  improved,  and 
some  expectoration  followed  coughing.  The  wound  suppurated  kindly, 
and  was  closed  by  the  end  of  the  second  week,  when  the  patient  left  the 
hospital  free  of  cough,  and  his  voice  restored  to  its  former  healthy  and 
natural  state. 

This  case  is  remarkable,  and  full  of  interest,  and  will  long  remain  a  soli- 
tary one  in  the  annals  of  surgery.  There  could  be  no  doubt  (from  the  his- 
tory and  symptoms)  that  a  foreign  body  had  lodged  in  the  larynx,  still  there 
was  some  hesitancy  in  admitting  that  so  large  a  substance  as  an  American 
copper  cent  could  pass  the  rima  glottidis  and  enter  the  cavity  of  the  larynx. 
Considering,  however,  the  laxity  of  the  tissues  in  the  aged,  the  volume  and 


1863.]    Walter,  Removal  of  Foreign  Bodies  from  Air-Passages.  61 

force  of  a  current  of  air  in  sudden  inspiration  during  the  act  of  laughing, 
and  the  great  capacity  of  the  air-passages  in  some  persons,  the  case  will  no 
longer  appear  surprising.  The  entire  absence  of  secretion  in  the  trachea, 
or  mucous  rales  in  the  bronchia,  where  a  foreign  body  so  long  occupied  the 
larynx,  seemed  strange,  and  can  only  be  accounted  for  by  its  being  of  a 
smooth  surface  and  firmly  fixed  in  its  situation,  its  presence  was  the  less 
felt  by  the  trachea.  In  addition  to  the  abnormal  artery  traversing  across 
the  trachea,  and  which  in  a  less  careful  dissection  must  have  been  wounded, 
both  radials  were  found  bifurcated  high  above  the  wrists. 

Case  6.  Mary,  infant  daughter  of  Robert  Hanna,  of  West  Deer  Town- 
ship, Alleghany  County,  aged  thirteen  months,  was,  in  May,  185?,  brought 
to  our  hospital,  a  roasted  coffee  bean  having  lodged  in  the  windpipe  some 
twelve  days  before ;  the  child  was  seen  to  convey  it  to  the  mouth,  when  it 
suddenly  disappeared.  She  instantly  began  to  cough  with  a  croupy  sound, 
but  did  not  appear  to  strangle.  The  cough  continued  in  spells;  she  became 
feverish  and  restless ;  a  week  later,  on  two  occasions,  while  coughing,  she 
was  nearly  suffocated.  On  examination  of  the  chest,  bronchial  rales  were 
audible  over  both  lungs;  the  presence  of  the  bean  seemed  to  interfere  but 
little  with  respiration  ;  it  could  be  distinctly  heard  to  move  up  and  down 
the  trachea  during  the  fits  of  coughing ;  the  pulse  was  accelerated ;  sleep 
short  and  disturbed.  On  May  2T,  assisted  by  Drs.  Henderson,  McGrath, 
and  Pillichody,  I  made  an  opening  into  the  trachea  to  the  extent  of  five- 
eighths  of  an  inch,  with  little  loss  of  blood ;  a  violent  fit  of  coughing  en- 
sued. On  its  subsiding,  a  female  catheter  was  introduced  by  the  wound 
through  the  larynx,  exploring  its  cavity  into  the  fauces,  but  no  obstruction 
was  detected.  The  efforts  at  coughing  were  very  violent,  during  which  the 
child  was  nearly  strangled,  became  purplish,  and  ceased  to  breathe,  the  bean 
having  momentarily  obstructed  the  ingress  of  air.  By  promptly  lifting  the 
child  up,  turning  its  head  downwards  and  slapping  on  its  back,  the  foreign 
body  became  displaced  and  respiration  restored.  The  edges  of  the  wound 
being  held  apart  with  blunt  hooks,  during  a  fit  of  coughing  the  bean  ap- 
peared in  sight,  was  instantly  seized  and  removed.  Relief  was  immediate ; 
the  cough  subsided ;  she  took  the  breast  with  ease,  and  slept  better.  The 
voice  remained  for  several  days  hoarse.  The  wound  inflamed,  and  though 
carefully  approximated,  opened  during  the  fits  of  coughing,  and  owing  to 
the  strumous  constitution  and  the  escape  of  milk  through  the  opening 
during  the  act  of  nursing,  the  closing  of  the  wound  was  tedious.  Dentition 
also  added  its  irritation  and  increased  the  vascular  excitement,  to  allay 
which  venesection,  with  local  depletion  by  leeches  applied  to  the  head  and 
throat,  and  other  antiphlogistics,  were  had  recourse  to.  By  strips  of  adhe- 
sive plaster  encircling  the  neck,  the  edges  of  the  wound  were  kept  in  close 
apposition,  and  after  three  weeks  were  united ;  a  week  later  the  wound  was 
cicatrized,  the  cough  had  disappeared,  and  recovery  being  complete,  the 
patient  was  taken  home. 

Case  1.  John  Adams,  of  Pittsburg,  aged  four  and  a  half  years,  a  healthy 
boy,  was,  while  eating  sugared  corn,  suddenly  attacked  with  croupy  cough 
and  strangulation,  which  lasted,  with  short  intermissions,  for  several  hours. 
The  parents  and  their  friends  felt  certain  that  a  corn  had  entered  the  wind- 
pipe, but  a  practitioner  who  was  called  in  ridiculed  the  idea  of  anything 


62      Walter,  Removal  of  Foreign  Bodies  from  Air-Passages.  [Jan. 

being  able  to  enter  the  windpipe,  and  treated  the  case  as  a  catarrh.  Six 
weeks  were  spent  in  fruitless  efforts  to  relieve  the  child  by  remedies  for 
croup,  catarrh,  and  bronchitis,  the  physician  continually  representing  the 
case  as  free  from  danger,  and  quieting  the  apprehension  of  the  parents.  At 
length,  tired  of  his  services,  I  was  requested  to  visit  him,  on  the  20th  of 
January,  1851.  From  the  history  of  the  case,  the  obstinately  harassing 
croupy  cough,  the  hectic  fever,  with  night-sweats,  loss  of  appetite,  emacia- 
tion, rapid  small  pulse,  quick  respiration,  profuse  ropy  expectoration,  dis- 
turbed sleep,  with  the  head  raised  by  pillows,  it  was  evident  a  foreign  body 
occupied  some  portion  of  the  bronchia.  On  examination  I  found  entire 
absence  of  respiratory  murmurs  in  the  left  lung,  with  dulness  on  percussion, 
while  the  right  lung  was  normal.  The  head  was  bent  forward  and  cannot 
be  raised  without  causing  pain  in  the  trachea.  The  corn  was  lodged  evi- 
dently in  the  left  bronchus,  and  softening  with  the  surrounding  moisture 
lay  impacted  with  little  hope  of  its  being  dislodged.  Hopeless  as  the  case 
appeared,  still  no  alternative  was  left  to  reach  the  offending  body  but  by 
opening  the  trachea.  The  parents  being  apprised  of  the  necessity  as  well 
as  the  uncertainty  of  the  operation,  in  this  particular  instance,  eagerly  de- 
sired to  have  it  performed,  however  small  the  chances  of  saving  the  child 
might  be.  Kindly  assisted  by  Drs.  Gazzam,  Murdock,  and  McDonald,  the 
trachea  was  opened  ;  the  bleeding  was  considerable.  During  the  paroxysms 
of  coughing  and  the  struggles  of  the  patient,  the  lips  of  the  wound  being 
held  apart,  an  elastic  sound  was  passed  upwards  through  the  larynx  into 
the  fauces.  No  obstruction  being  met,  it  was  allowed  to  slide  downward 
towards  the  left  bronchus  with  the  view  of  dislodging  the  corn  ;  the  body 
too  was  inverted,  the  back  repeatedly  slapped,  but  all  efforts  failed  in  dis- 
lodging and  expelling  the  body.  Convinced  that  it  had  become  impacted 
in  the  bronchus  by  becoming  swollen,  we  contented  ourselves  with  keeping 
the  windpipe  open  with  a  wire  spring.  Some  relief  was  thus  afforded  the 
little  sufferer,  respiration  became  less  hurried,  pulse  less  frequent,  and  the 
cough  less  troublesome.  The  respite  was,  however,  of  short  duration ;  the 
croupy  cough  continued,  with  profuse  ropy  expectoration,  which  soon  be- 
came highly  offensive.  Emaciation  and  restlessness  increased,  the  lips  of 
the  wound  assumed  a  pale  colour,  and  gaped.  Diarrhoea  set  in,  with  ascites 
and  general  oedema,  and  death  closed  the  scene  three  weeks  after  the  per- 
formance of  the  operation.  Anxious  to  verify  our  diagnosis,  a  post-mortem 
examination  was  readily  obtained,  twenty-four  hours  after  death.  On 
opening  the  chest,  the  right  lung  and  pleura  were  found  normal;  on  the 
left  the  pleura  pulmonalis  et  costata  were  adherent  throughout  their  entire 
extent.  The  lung  was  congested,  enlarged,  and  the  air-cells  filled  with 
depots  of  purulent  matter.  The  pericardium  was  distended  with  serum ; 
the  bronchi  were  filled  with  ropy  mucus;  the  larynx  natural,  but  the  trachea 
and  left  bronchus  were  inflamed.  In  the  latter  was  found  a  red  corn,  soft- 
ened, and  firmly  wedged  in,  completely  shutting  up  the  bronchus.  The 
examination  having  fully  verified  the  diagnosis,  it  next  elicited  our  regret 
that  science  should  have  been  so  outraged  by  one  of  its  votaries  in  dooming 
a  healthy  child  to  death,  whom  prompt  surgical  treatment  would  have 
restored  to  health. 

We  hope  no  apology  is  needed  for  laying  before  the  professional  reader 
the  foregoing  cases.  The  report  of  cases  conveys  much  instruction  ;  they 
are  the  landmarks  for  the  young  practitioner,  which  enable  him  to  act  with 


1863.]       Bill,  New  Method  of  Performing  Traelieotomy.  63 

promptness  and  confidence  in  cases  of  emergency,  though  individual  expe- 
rience be  wanting. 

Tracheotomy  is,  in  general,  a  simple  operation ;  the  division  of  the  skin, 
cellular  tissue,  and  superficial  fascia  is  easy  enough.  The  reaching  of  the 
median  line  of  the  .trachea  between  the  muscles  alone  may  require  caution, 
as  bleeding  and  struggling  will  obscure  the  field  of  operation.  To  miss 
this  median  line  and  cut  the  muscles  is  embarrassing  to  the  young  surgeon. 
Not  much  difficulty  is  met  with  in  incising  the  trachea,  yet  occasionally  the 
operation  may  become  harassing  to  the  surgeon  from  the  struggles  of  the 
patient,  the  shortness  of  the  neck,  the  deep  situation  of  the  trachea  in 
children,  the  convulsive  paroxysms  of  coughing  and  fits  of  strangulation 
which  take  place  on  the  interior  of  the  windpipe  being  exposed  to  the 
external  air. 

Temporary  strangulation,  or  even  death,  may  occur  at  the  moment  when 
success  seemed  certain,  from  the  foreign  body  becoming  impacted  in  the 
lower  portion  of  the  tube,  completely  arresting  the  ingress  of  air  in  such 
circumstances.  Inversion  of  the  body,  with  shaking  and  slapping  on  the 
back,  or  the  speedy  introduction  of  a  sound  or  forceps  down  to  the  bifurca- 
tion, will  be  the  most  efficient  means  of  relief. 

The  after-treatment  of  tracheotomy  must  be  strictly  antiphlogistic,  free 
and  repeated  bleeding,  general  or  local,  or  both,  according  to  circumstances, 
to  control  inflammatory  tendencies,  and  remove  congestion  of  the  mucous 
membrane  of  the  air-passages.  The  administration  of  anaesthetic  agents 
would  be,  if  not  improper,  of  very  doubtful  propriety  in  the  cases  under 
consideration,  as  tending  to  shut  off  from  the  lungs  the  necessary  supply  of 
oxygen,  already  too  limited,  by  the  presence  of  the  foreign  body.  More- 
over, the  efforts  of  the  patient  are  useful,  in  fact  needed,  to  expel  by  cough- 
ing, or  snore,  the  substance  into  the  opening  for  its  removal. 


Art.  VI. — A  JSfeiv  Method  of  Performing  Tracheotomy,  with  two 
Illustrative  Cases.    By  J.  H.  Bill,  Asst.  Surg.  U.  S.  A. 

It  is  acknowledged  by  operators  that  tracheotomy  is  sometimes  one 
of  the  most  difficult  operations  in  surgery,  taxing  the  coolness,  skill,  and 
knowledge  of  the  surgeon  to  the  utmost  extent. 

The  parts  involved  lie  so  deeply,  are  so  surrounded  by  important  vessels, 
are  so  plentifully  supplied  with  veins,  are  so  mobile  in  themselves,  that 
even  supposing  perfect  docility  on  the  part  of  a  patient,  the  operation 
may  be  of  very  difficult  execution.  Moreover,  in  no  case  is  it  an  operation 
that  can  be  done  hastily,  and  at  the.  same  time  with  safety ;  and  yet  cir- 
cumstances often  demand  that  it  should  be  performed  without  a  moment's 
delay. 


64  Bill,  New  Method  of  Performing  Tracheotomy.  [Jan. 

We  propose  in  this  article  to  offer  a  method  to  the  profession  which  we 
believe  greatly  reduces  the  danger  of  the  operation,  and  certainly  renders 
its  rapid  performance  both  safe  and  easy. 

What  are  the  dangers  attendant  on'  tracheotomy  as  an  operation  ?  They 
are  two  in  number.  The  danger  of  opening  a  great  vessel  at  the  root  of 
the  neck,  and  the  danger  of  hemorrhage  into  the  trachea  from  wounded 
tracheal  or  thyroid  veins. 

The  first  of  these  dangers  may  be  converted  into  a  reality  by  an  incautious 
downward  or  lateral  extension  of  the  incision,  or  owing  to  the  unsteadiness 
of  the  trachea  and  the  slipping  and  rolling  of  this  under  the  point  of  the 
knife.  The  latter  accident  may  arise  from  over  anxiety  to  open  the  trachea 
before  the  hemorrhage  from  the  thyroideal  and  other  tissues  has  been 
checked. 

Feeling  the  necessities  of  the  case,  and  the  difficulties  and  dangers 
attendant  upon  the  operation,  the  writer,  several  years  since,  devised  a 
modification  of  the  old  method,  and  he  has,  by  two  trials  on  the  living 
subject,  as  well  as  by  numerous  repetitions  of  these  on  the  cadaver,  reason 
to  be  perfectly  satisfied  with  the  operation  proposed. 


Fig.  l. 


Fig.  1  represents  the  instrument  employed  of  one-half  the  required  size. 
It  is,  in  fact,  a  trocar  and  canula  of  peculiar  shape.  The  canula  presents 
an  elliptical  section ;  the  point  of  the  trocar  is  shaped  like  the  point  of 
an  ordinary  curved  bistoury,  blunt  on  the  back.  The  instrument  is  pro- 
vided with  rings  at  a,  to  serve  as  handles  for  manipulation.  That  portion 
of  the  rod  of  the  trocar  lying  between  b  and  c,  is  smaller  than  the  rest, 
and  has  a  watch-spring  temper.  There  is  a  fenestra  at  c.  The  canula 
is  silver,  the  trocar  steel.  Such  is  the  instrument.  The  operation  proposed 
is  the  following  : — 

Make  an  incision  through  the  crico-thyroid  membrane  parallel  to  the 
crico-thyroid  arteries.  Having  sheathed  the  spear  point  of  the  trocar  within 
the  canula  by  partly  withdrawing  the  former  from  within  the  latter,  pass 
the  open  mouth  of  the  canula  through  the  incision  so  made,  and  carry 
the  instrument  as  far  downwards  as  is  considered  safe  or  necessary,  the 
convexity  of  course  looking  towards  the  oesophagus.  When  this  point 
lias  been  reached,  depress  the  ring  handles  of  the  canula  towards  the 
patient's  chin.  By  so  doing  the  mouth  of  the  canula  is  elevated,  and  also 


1863.]       Bill,  New  Method  of  Performing  Tracheotomy.  65 

with  it  the  anterior  wall  of  the  trachea  against  which  it  has  been  press- 
ing.. The  great  vessels  are  now  of  necessity  behind  and  to  the  outside 
of  the  ordinary  line  of  incisions ;  and  these  can  be  in  no  danger  whatever 
when  we  push  the  handle  of  the  trocar  into  its  place,  and  so  protrude  the 
knife  edge  through  the  canula,  and  through  all  the  tissues  lying  in  front 
of  this.  The  whole  instrument  is  now  to  be  pushed  on,  until  the  mouth 
of  the  canula  has  made  its  way  through  the  skin,  and  then  the  stilet  being 
withdrawn  the  patient  is  allowed  to  breathe  temporarily  through  the  canula 
by  means  of  the  fenestra  at  c.  If  the  operation  was  undertaken  for  the 
removal  of  a  foreign  body,  we  should  now  proceed  regularly  to  work  as  in 
ordinary  operations,  making  incisions  through  the  skin  and  fascia  of  one 
or  two  inches  in  length,  separating  the  muscle  and  securing  all  tissues  each 
side  of  the  intended  incision  through  the  trachea,  by  passing  underneath 
them  bent  needles,  and  twisting  a  thread  over  these  in  the  manner  of  the 
interrupted  suture.  All  this  done,  introduce  a  probe-pointed  bistoury  into 
the  mouth  of  the  canula  and  the  lip  of  the  incisions,  through  skin,  fascia, 
and  the  muscles  being  held  asunder  by  blunt  hooks,  carry  canula  and 
bistoury  carefully  upward  until  three  or  four  tracheal  rings  are  divided. 
Then  remove  the  bistoury  from  the  canula  and  withdraw  this  latter  from 
the  wound  within  the  crico-thyroid  membrane.  The  search  for  the  foreign 
body  may  now  be  instituted  with  perfect  safety. 

If  the  operation  was  undertaken  for  another  purpose  than  the  removal 
of  a  foreign  body,  a  different  plan  is  recommended.  After  withdrawing 
the  stilet  from  the  canula  take  a  tracheotomy  tube  that  will  just  fit  tightly 
in  the  mouth  of  the  canula,  and,  having  adjusted  them  relatively  in  this 
way,  slowly  withdraw  the  mouth  of  the  canula  through  the  wound,  and,  at 
the  same  time,  push  the  mouth  of  the  tracheotomy  tube  into  its  place,  until 
this  latter  is  fairly  lodged  into  the  trachea.  Then  the  canula  may  be  with- 
drawn through  the  wound  in  the  crico-thyroid  membrane.  This  latter 
method  would  be,  perhaps,  a  good  operation  in  cases  requiring  it  from 
drowning,  etc. 

Such  is  the  operation  we  propose,  and  which  we  intend  in  future  to 
perform.  In  conclusion,  we  will  briefly  detail  two  cases  operated  upon  by 
this  principle,  i.  e.,  the  fixation  of  the  trachea  and  the  elevating  it  away 
from  the  great  vessels  before  making  the  incisions  into  it. 

The  first  case  was  that  of  private  Henry,  Mounted  Rifles,  occurring  at 
Fort  Union,  during  the  winter  of  1858. 

This  man  was  found  drunk  by  his  orderly  sergeant  and  temporarily  con- 
fined in  a  privy ;  one  hour  afterwards,  at  6  P.  M.,  he  was  discovered  to  be 
dying.  He  was  carried  to  the  hospital,  where  the  steward,  by  dint  of 
pounding,  etc.,  caused  the  poor  fellow  to  disgorge  a  bit  of  meat  which  he 
had  vomited  into  his  trachea  or  rather  his  larynx.  I  arrived  as  soon  as 
possible,  and  found  the  patient  perfectly  comatose  and  pulseless.  The 
apnoea  was  complete.  It  was  so  dark  that  I  could  scarcely  recognize  the 
man's  features,  and  candles  were  not  at  hand.  Feeling  that  no  delay  was 
No.  LXXXIX.— Jan.  1863.  5 


66  Bill,  New  Method  of  Performing  Tracheotomy.  [Jan. 

allowable,  I  at  once  plunged  a  common  lancet  into  the  crico-thyroid  mem- 
brane, and  introduced  a  catheter,  carried  its  point  down  to  the  part  of  the 
trachea  I  wished  to  open,  and  depressing  its  handle  I  thus  elevated  the 
point  of  the  instrument,  and  with  it  the  trachea.  I  then  plunged  the  lan- 
cet into  the  mouth  of  the  catheter  and  divided  all  the  tissues  upwards  by 
simply  withdrawing  the  catheter  and  with  it  the  lancet.  The  man  breathed 
his  last  before  the  operation  commenced,  although  every  method  for  his 
recovery,  including  Marshall  Hall's,  was  tried  for  an  hour  and  upwards, 
but  in  vain. 

I  may  mention,  incidentally,  that  after  making  the  incision  in  the  crico- 
thyroid membrane  and  withdrawing  the  lancet,  I  was  puzzled  for  an  instant 
by  the  protrusion  through  the  wound  of  a  singular  looking  substance  of 
the  nature  of  a  tumour.  In  the  darkness,  I  guessed  that  it  was  a  bit  of 
meat,  and  accordingly  pushed  it  into  the  gullet  with  my  little  finger  before 
introducing  the  catheter.  The  operation  did  not  consume  more  than  thirty 
seconds  time,  and  the  autopsy  next  day  showed  that  the  wound  in  the  tra- 
chea was  exactly  in  the  mesial  line,  and  that  no  vessel  of  any  size  had  been 
cut.  The  parts  involved  are  now  in  my  possession.  The  hemorrhage  was 
profuse,  though  not  more  so  than  might  have  been  expected  considering  the 
congestion  caused  by  the  union  of  drunkenness,  strangulation,  and  the  resi- 
dence for  an  hour  in  the  stifling  atmosphere  of  a  privy.  The  autopsy  re- 
vealed an  enormously  enlarged  thymus  gland,  weighing  210  grains.  The 
deceased  suffered  from  secondary  syphilis  and  all  the  glands  of  the  neck 
were  much  enlarged. 

The  second  case  occurred  at  Fort  Defiance,  N.  M.,  in  the  spring  of 
1860.  A  child  of  a  camp  follower,  aged  5  years,  possessing  a  neck  and 
disposition  peculiarly  unfitted  for  tracheotomy,  had  inhaled  a  bit  of  a 
bean  or  a  grain  of  corn.  She  was  almost  suffocated,  and  as  there  were 
no  auscultatory  signs  of  any  foreign  body  in  the  bronchi  or  trachea,  and 
as  there  was  a  singular  whistling  noise  in  the  larynx,  I  diagnosed  a  foreign 
body  jn  the  ventricles  of  the  latter.  Much  to  the  little  patient's  disgust  an 
incision  was  made  through  the  skin  over  the  crico-thyroid  membrane,  this 
latter  punctured  and  a  grooved  director  carried  down  the  trachea  a  short 
distance.  By  depressing  the  handle  of  the  grooved  director  the  point  was 
raised,  and  along  with  the  latter  the  trachea,  which  was  thus  carried  away 
from  the  great  vessels,  and  fixed.  As  haste  was  no  object,  I  carefully  by 
regular  incisions  divided  skin,  superficial  and  cervical  fasciae,  then  sepa- 
rated the  muscles  of  the  trachea,  and  held  them  asunder  by  means  of  small 
blunt  hooks,  to  which  fine  chains  were  attached  loaded  with  weights,  and 
the  latter  having  been  thrown  over  the  edge  of  the  table  kept  the  trachea 
well  exposed.  I  thus  obviated  the  necessity  of  an  assistant,  who  was  not 
to  be  obtained.  Now  came  the  difficulty  of  the  operation  ;  the  child  was 
angry  and  frightened,  and  spit  in  my  face  until  I  was  nearly  blind.  First, 
the  isthmus  of  the  thyroid  was  secured  by  two  twisted  sutures,  in  the  man- 
ner of  Brainard ;  hemorrhage  thus  prevented,  the  trachea  was  now  well 
lifted  away  from  the  great  vessels,  and  although  I  was  nearly  blind  as  before 
stated,  with  a  feeling  of  delightful  security  I  pushed  a  knife  through  the 
thoroughly  fixed  trachea,  and  slit  upwards  two  or  three  of  its  rings,  simply 
by  sliding  the  knife  along  the  groove  of  the  director.  This  latter  was  then 
withdrawn.  I  then  bent  the  scoop  of  the  director  so  that  it  resembled  the 
Graefe  aneurism  needle,  and  passed  it  into  the  ventricle  of  the  larynx.  In 
doing  so,  I  felt  something  give  way  or  slip  from  under  the  instrument.  It 


1863.] 


Blake,  Primary  Pyaemia. 


61 


proved  to  be  a  grain  of  corn  or  a  bean,  which  the  child  evacuated  per  anum 
thirty-six  hours  after,  so  much  altered  as  to  be  unrecognizable.  A  small  por- 
tion of  the  husk  of  the  same  was  brought  away  in  the  scoop  of  the  director. 
It  was  lodged  in  the  ventricle  of  the  larynx,  and  was  large  enough  to  do  much 
harm.  The  patient  still  breathed  with  great  difficulty  from  the  tumefaction 
of  the  mucous  membrane,  and  as  a  precautionary  measure  it  was  thought 
best  to  keep  the  wound  open  for  twenty-four  hours.  Small  doses  of  calomel 
and  tartar  emetic  were  given  every  two  hours,  the  trachea  was  moistened 
every  few  minutes  with  a  few  drops  of  glycerin  and  fumigations  of  acetic 
acid  employed.  In  about  thirty-six  hours,  finding  that  the  patient  was  able 
to  breathe  through  the  larynx,  I  closed  the  wound  in  the  trachea  by  some 
fine  wire  suture,  and  left  the  patient,  directing  quiet  and  confinement  for  a 
few  days.  In  three  weeks  the  wound  was  healed,  excepting  a  small  fistu- 
lous orifice  in  the  trachea.  By  frequent  applications  of  nitrate  of  silver 
this  closed  also.  And  the  patient  is  now,  three  months  after  the  operation, 
quite  well. 

We  deem  that  enough  has  been  said  to  show 

1st.  That  the  method  proposed  is  far  safer  than  the  old  plan;  and, 
2d.  That  it  may  be  performed  more  rapidly  and  easily. 


Art.  VII. —  Case  of  Primary  Pyaemia.    By  James  Blake,  M.D., 
F.RC.S.  San  Francisco,  California. 

The  occurrence  of  cases  of  primary  pyaemia  is  so  rare,  that  I  think  the 
following  instance  of  a  most  acute  form  of  the  disease  is  worth  publishing. 
In  most  systematic  works  on  medicine,  the  existence  of  such  a  form  of  dis- 
ease is  not  noticed.  Wunderlich,  however,  in  the  Archiv.  fur  Physio- 
logische  Heilkunde,  for  1857,  relates  five  cases  that  he  had  met  with  in 
his  extensive  practice.  In  only  one  instance,  however,  was  the  disease  so 
rapidly  fatal  as  in  the  following  case,  and  even  in  that  it  was  preceded  by 
circumstances  which  were  much  more  calculated  to  give  rise  to  a  vitiated 
state  of  the  blood.  As  far  as  my  knowledge  of  medical  literature  enables 
me  to  judge,  the  accompanying  case  is  unique  in  the  apparent  absence  of 
all  those  antecedents  which  have  generally  been  regarded  as  essential  to 
the  development  of  the  disease. 

G.  L.,  set.  14,  a  strong,  healthy  boy;  has  always  enjoyed  good  health, 
having  even  escaped  up  to  the  present  time  all  the  infantile,  eruptive 
fevers  and  hooping  cough,  although  frequently  exposed  to  them.  On  July 
23d,  whilst  playing,  and  on  the  ground,  he  received  a  kick  in  the  thigh 
from  one  of  his  school-fellows.  The  kick  caused  him  some  pain,  so  that 
he  sat  down  for  about  half  an  hour.  He  did  not  complain  on  returning 
home,  and  the  next  day  he  went  to  school  as  usual,  walking  a  considerable 
distance  ;  but  on  coming  home  in  the  evening  he  was  lame,  and  complained 


G8 


Blake,  Primary  Pyaemia. 


[Jan. 


of  his  leg  hurting  him.  At  night  he  was  rather  restless  and  feverish.  The 
next  morning  (the  25th),  the  leg  was  more  painful,  the  thigh  being  swollen 
and  red.  There  was  a  decided  chill  about  9  A.  M.,  followed  by  fever  and 
loss  of  appetite.  The  pain  in  the  leg,  swelling,  and  redness  increased 
towards  evening,  and  all  night  he  was  in  a  high  fever,  and  frequently 
delirious. 

I  saw  him  for  the  first  time  on  the  morning  of  the  26th.  I  found  the 
right  thigh  considerably  swollen  and  red,  the  swelling  extending  from  a 
little  below  the  groin  down  to  the  knee,  but  most  marked  at  about  the 
junction  of  the  upper  and  middle  third.  There  was  some  hardness,  and  a 
feeling  of  elastic  tension.  Handling  the  part  caused  considerable  pain, 
and  there  was  great  tenderness  on  pressure  over  a  spot  on  the  outside  of 
the  thigh,  about  three  inches  below  the  trochanter,  the  place  where  it  was 
stated  that  he  had  been  kicked.  There  was  however  no  ecchymosis,  nor 
anything  except  the  increased  pain,  to  indicate  that  this  was  the  seat  of 
the  original  injury.  The  movements  of  the  hip  could  be  performed  pas- 
sively without  pain,  nor  was  there  any  symptom  of  injury  about  the  joint. 
The  child  complained  only  of  violent  headache  and  pain  in  the  thigh. 
There  was  great  thirst,  and  complete  anorexia.  The  bowels  had  been 
freely  opened  by  a  saline  purge.  The  skin  was  hot  and  dry  ;  tongue  white  ; 
pulse  120,  full. 

The  diagnosis  was,  that  there  was  inflammation  going  on  beneath  the 
fascia  lata.  I  proposed  an  incision  on  the  outside  of  the  thigh,  more  with 
the  view  of  relieving  tension  and  preventing  infiltration  than  in  the 
expectation  that  pus  had  already  formed.  The  parents  wishing  a  second 
opinion,  I  met  Dr.  Dupuytren  in  consultation  on  tne  case  in  the  afternoon, 
and  his  views  coinciding  with  mine,  an  incision  two  and  a  half  inches  long 
was  made  down  to  the  bone.  Nothing  escaped  but  some  blood  and  serum. 
Tincture  of  veratrum  viride  and  spirit  mindereri  was  ordered  to  allay  the 
fever,  and  morphia  in  full  doses  to  procure  sleep. 

July  21.  The  child  has  passed  a  restless  night,  except  when  stupefied 
at  short  intervals  by  the  morphia,  of  which  as  much  as  two  grains  have 
been  taken.  When  awake  he  has  been  wildly  delirious.  Skin  hot ;  pulse 
110,  full;  great  thirst;  tongue  coated  white.  Features  express  anxiety; 
skin  of  a  dull,  brownish-yellow  colour.  The  thigh  is  rather  more  swollen, 
and  pain  is  complained  of  in  each  lower  extremity.  Both  ankles  are  rather 
swollen  and  look  red.  Small  collections  of  pus  are  observed  on  each  lower 
extremity.  They  seem  to  be  directly  beneath  the  epidermis,  and  vary  in 
size  from  a  pin's  head  to  a  pea ;  some  are  umbilicated.  There  are  about 
twenty  on  each  limb,  situated  mostly  below  the  knee.  In  fact,  there  were 
none  on  the  injured  thigh,  and  but  two  or  three  on  the  other.  None  were 
found  on  the  arms,  face,  or  trunk. 

In  the  evening  the  pulse  was  down  to  90  ;  some  perspiration  had  taken 
place,  but  the  patient  was  delirious  nearly  the  whole  time.    Some  egg  and 


1863.] 


Blake,  Primary  Pyaemia. 


69 


brandy  was  ordered,  and  tinct.  ferri  sesquichlor.  in  twenty  drop  doses  every 
three  hours.  One-third  grain  morphia  was  to  be  taken  every  hour  until 
he  slept.  It  was  now  evident  that  the  symptoms  were  not  owing  to  in- 
flammation or  abscess  beneath  the  fascia  lata,  and  as  the  patient  rapidly 
became  worse,  the  only  conclusion  that  we  could  arrive  at  was,  that  it  was 
a  case  of  blood  poisoning.  The  case  was  seen  by  Dr.  Toland  and  two 
other  physicians,  and  whilst  the  symptoms  now  clearly  pointed  out  the 
nature  of  the  disease,  yet  we  could  see  no  apparent  cause  for  its  proving 
so  rapidly  fatal.  The  patient  died  on  the  morning  of  the  30th,  or  five 
days  after  the  appearance  of  the  first  symptoms. 

Assisted  by  Dr.  Staub,  I  made  a  partial  examination  of  the  body  twelve 
hours  after  death,  as  we  were  only  permitted  to  open  the  thorax  and  abdo-  ' 
men.  On  opening  the  thorax,  the  lungs  collapsed  but  partially,  as  they 
were  pretty  generally  affected  by  a  sero-sanguinolent  engorgement.  On 
the  surface  of  the  lungs,  and  immediately  beneath  the  pleura,  were  a  num- 
ber of  small  abscesses,  and  on  cutting  into  them,  small  collections  of  pus 
were  found  throughout  the  whole  of  the  pulmonary  tissue.  These  abscesses 
were  small,  the  largest  not  being  larger  than  a  small  bean.  On  opening 
the  pericardium  it  was  found  to  contain  about  three  ounces  of  serum,  and 
some  shreds  of  detached  fibrin.  The  surface  of  the  heart,  as  well  as  of  the 
free  surface  of  the  pericardium,  was  rough.  At  the  base  of  the  heart,  near 
the  origin  of  the  aorta,  there  was  an  appearance  of  ecchymosis  in  the  mus- 
cular tissue,  and  on  cutting  into  it  an  ill-defined  purulent  collection  was 
found  almost  the  size  of  a  quarter  of  a  dollar.  The  right  cavities  contained 
some  decolorized  fibrinous  clots,  which  extended  some  distance  into  the 
pulmonary  artery.  The  blood  in  the  left  cavities  was  dark  and  fluid,  but 
some  of  it  that  was  preserved  for  examination  coagulated  after  a  few  hours. 
The  lining  membrane  was  healthy.  The  liver  and  spleen  appeared  nor- 
mal ;  a  careful  examination  failed  to  detect  any  purulent  deposits  in  either 
of  these  organs,  nor  was  the  spleen  at  all  softened.  The  kidneys  presented 
on  their  surface  a  number  of  small  collections  of  pus,  analogous  to  those 
seen  on  the  skin,  and  situated  immediately  under  the  capsule.  There  were 
about  a  dozen  of  these  on  the  surface  of  each  kidney,  some  of  which  were 
surrounded  by  an  ecchymosed  border.  The  substance  of  the  kidneys  was 
darker  than  natural,  particularly  the  right,  but  no  purulent  collections 
were  found  except  on  the  surface.  The  iliac  veins  of  each  side,  and  the 
lower  part  of  the  cava,  were  examined.  There  was  no  clot  in  either ;  but 
the  lining  membrane  of  the  right  iliac  was  not  so  smooth  as  that  of  the 
opposite  side.  A  microscopical  examination  of  the  blood,  taken  from  the 
left  side  of  the  heart,  showed  the  corpuscles  to  be  nearly  all  altered  in 
shape ;  hardly  one  could  be  found  with  the  natural,  clear  contour ;  they 
were  mostly  irregular,  presenting"  generally  a  stellate  form.  The  propor- 
tion of  colourless  corpuscles  was  rather  larger  than  natural,  and  they  were 

I le  s  transparent,  presenting  the  appearance  between  normal  colourless  cor- 


10  Browne,  Ligation  of  the  Subclavian.  [Jan. 

puscles,  and  pus  globules.  The  microscope  showed  the  urinary  tubes 
loaded  with  pus  globules  and  epithelium. 

Such  is  the  history  of  the  case.  There  can  be  no  doubt  but  that  death 
was  caused  by  pyaemia ;  but  the  rapidity  of  the  disease  in  a  previously 
healthy  child,  and  the  slightness  of  the  apparent  cause,  are  points  which 
make  it  interesting.  The  child's  general  health  was  excellent;  it  had  no 
illness  for  years,  having  escaped  the  eruptive  fevers,  and  other  children's 
diseases,  although  frequently  exposed  to  them.  And  yet,  under  these  cir- 
cumstances, a  slight  bruise,  so  slight' as  hardly  to  leave  a  mark  oh  the  skin, 
sufficed  to  develop  a  disease  which,  in  four  days,  had  so  far  affected  the 
system  that  pus  was  deposited  on  the  internal  organs  and  on  the  skin.  A 
bruise  was  received  on  the  23d,  at  noon ;  no  symptoms  of  importance 
showed  themselves  until  the  morning  of  the  25th,  when  there  was  a  chill; 
and  on  the  morning  of  the  21th,  or  forty-eight  hours  after  the  chill,  puru- 
lent deposits  were  formed  beneath  the  skin,  and  most  likely  on  the  internal 
organs.  Death  took  place  early  on  the  30th,  or  less  than  five  days  after 
the  appearance  of  the  first  well  marked  symptoms.  -4  most  careful  inquiry 
failed  to  connect  the  disease  with  any  extraneous  source  of  poisoning.  The 
only  antecedent  that  might  be  thought  to  have  been  connected  with  the 
appearance  of  the  disease  was,  that  two  months  previous  to  his  illness  the 
child  had  ridden  into  the  water  a  horse  that  was  said  to  have  had  sores  on 
its  body ;  but  this  was  entirely  accidental,  as  the  child  was  not  accustomed 
to  be  with  horses.  The  eruption  on  the  skin  was  analogous  to  that  seen  in 
cases  of  farcy;  but  the  absence  of  any  affection  of  the  mucous  membranes  of 
the  nose  or  throat — the  length  of  time  that  had  elapsed  since  exposure  to 
the  possible  source  of  contagion — and  the  apparent  connection  of  the  dis- 
ease with  a  local  injury,  lead  to  the  conclusion  that  the  case  was  one  of 
primary  pyaemia. 

Note. — The  fact  of  the  child  never  having  had  any  of  the  eruptive  fevers  of 
childhood  might,  perhaps,  have  acted  as  a  predisposing  cause  for  the  disease. 


Art.  VIII. — Ligation  of  the  Subclavian  of  a  Negro.  Death  of  the  Pa- 
tient. With  some  Inquiries  as  to  its  Cause.  By  Rufus  King  Browne, 
M.  D.,  late  Brigade  Surgeon  U.  S.  V,  Surgeon  in  chief  U.  S.  General 
Hospital,  New  Orleans. 

A  case  of  ligation  of  the  subclavian  in  this  hospital  was  recently  reported 
by  Dr.  J.  B.  Muse,  of  this  hospital.  The  patient  afterwards  died.  At  the 
time  the  report  was  read  to  me,  I  had  no  opportunity  to  express  any  opinion 
on  the  exciting  cause  of  the  death.  No  untoward  or  peculiar  incidents 
up  to  the  occurrence  of  the  febrile  rigor  were  consequent  on  the  operation. 


1863.]  Browne,  Ligation  of  the  Subclavian.  71 


I  had  often  performed  it  on  the  cadaver.  I  have  not  since  been  successful 
in  imagining  any  cause  of  death  but  the  rigor,  though  it  is  supposable  that 
the  operation  itself  without  such  coincidence  may  terminate  fatally,  as  that 
did,  and  that  without  symptoms  of  gravity  plainly  attributable  to  it.  The 
patient  was  very  eligibly  situated  in  Hygienic  particulars  for  recovery,  and 
was  visited  several  times  a  day  by  myself  and  others.  The  patient  never 
complained  of  aught  but  a  slight  soreness  of  the  operated  part.  He  was 
cautiously  dieted  and  well  attended  by  his  wife  and  friends.  The  wound 
was  seen  on  each  visit  several  times  a  day  by  myself  and  dressed  by  my 
own  hands.  The  suspicion  of  empyema  is  precluded  by  the  absence  of 
any  indication  of  it  in  the  autopsy,  or  in  the  course  of  the  case.  He 
occupied  a  room  by  himself,  well  lighted  and  airy.  But  one  suspicion 
ever  crossed  my  mind  that  my  injunctions  had  been  disregarded;  this  was 
that  he  might  have  copulated  with  his  wife,  who  watched  him  one  night, 
but  this  was  positively  denied;  and  this  suspicion  was  precluded  by  the  fact 
that  in  such  cases  the  result,  if  any,  would  have  been  immediate  or  con- 
secutive on  the  act.    The  death  did  not  occur  until  late  in  the  forenoon. 

All  the  noticeable  incidents  antecedent  to  the  death  are  already  related. 
The  first  of  them  was  the  faintness  of  the  patient ;  when  risen  to  use  the 
chamber,  the  attendants  noticed  a  sudden  faintness,  weakness,  not  to  syn- 
cope. This  incident  was  the  first  of  the  closing  scenes  of  his  life.  It  was 
immediately  reported  to  me — only  two  rooms  separating  me  from  the 
patient's  bed — and  one  of  the  three  persons  with  him  at  the  time,  came  to 
me  at  once.  The  rigor  came  on  immediately  after.  This  faintness  indi- 
cated a  perturbed  or  labored  action  of  the  heart,  which  was  found  to  be 
the  fact ;  when  the  rigor  set  in,  the  hand  of  the  operated  side  at  once 
appeared  shrivelled.  He  complained  of  nothing  but  the  weakness.  Soon 
after  the  respiratory  movements  were  diminished  in  degree,  though  orderly, 
stimulants  were  prescribed,  and  while  they  were  being  taken,  a  renewed 
examination  was  made  of  the  cardiac  movement;  it  was  regular  in  meas- 
ure, but  labored.  The  heart  beat  was  not  circumscribed  to  the  apex,  but 
the  whole  ventricle  was  urged  against  the  precordial  space ;  the  pulse  was 
but  84.  To  the  last  he  complained  of  nothing  but  the  heart  "  keeping  a 
fooling."  There  was  no  other  sense  of  distress.  Under  the  influence  of 
the  stimulants  the  symptoms  of  rigor  were  dispelled.  The  sweat  on  the 
forehead  still  continued,  though  remarkably  abated,  but  the  skin  was  no- 
where cold.  This  condition  of  the  heart  continued  until  death.  There 
was  no  evident  engorgement  or  excitement  of  the  great  vessels  of  the  neck. 
Was  the  rigor  strictly  febrile,  or  was  it  a  consequence  of  the  operation, 
and  due  to  that  "  constitutional  irritation,"  so  well  described  by  Tyrrell  of 
London,  in  1824,  who  attributed  to  it  many  deaths  not  otherwise  accounted 
for  ?  Many  times  in  cases  with  or  without  serious  organic  lesion,  when 
we  have  been  at  a  loss  to  account  for  death,  this  hypothesis  seemed  reason- 
able.  The  location  of  the  hospital  is  highly  malarious ;  and  was  the  irrita- 


72 


Browne,  Ligation  of  the  Subclavian. 


[Jan. 


tiou  inaugurated  by  the  action  of  the  miasmatic  air  during  the  operation, 
on  the  exposed  tissue  ?  It  set  in  on  the  seventh  day  after  the  operation. 
The  wound  was  found  peculiarly  healthy  and  free  from  suppuration,  but 
far  from  dry.  Would  this  have  been  so  were  it  the  seat  of  an  infectious 
or  epidemic  influence ;  and  is  a  miasmatic  atmosphere  a  source  of  disaster 
in  the  existence  of  wounds  of  the  body  ? 

Such  are  the  questions  it  would  be  a  great  progress  in  pathology  to 
answer;  or  was  the  increase  of  blood  by  so  much  as  its  circuit  was  dimin- 
ished in  extent  too  great  for  the  normal  action  of  the  heart?  The  patient 
was  very  full  blooded  and  well  nourished.  This  supposition  would  attri- 
bute the  fatality  wholly  to  the  consequence  of  the  operation,  and  this  would 
hardly  take  the  choice  of  supposition  ;  for  shall  we  not  rather  suppose 
that  as  in  the  febrile  rigor  there  is  always  comparative  interior  congestion, 
a  relative  heaping  or  arrest  of  their  contents  nearest  the  centre  of  the  circu- 
latory system,  that  the  occurrence  of  the  rigor  was  the  co-efficient  cause  of 
the  laboring  condition  of  the  heart.  There  were  no  brain  symptoms,  and 
although  inspiration  was  abbreviated,  the  respiratory  movement  was  orderly 
and  unintermitted. 

To  the  last,  the  arterial  action  was  not  greatly  accelerated,  nor  the  car- 
diac movement  increased,  but  rather  oppressed,  as  though  the  blood  forced 
out  by  each  antecedent  stroke  had  not  been  hurried  away,  and  that  be- 
cause of  the  relative  increase  of  its  amount  in  the  same  calibre  to  contain 
it.  This  is  easily  apprehended,  or  what  was  first  shown  experimentally  by 
myself,  a  congestion  of  the  vascular  part  of  the  walls  and  thickness  of  the 
heart  itself. 

It  would  perhaps  bring  us  nearer  the  truth  to  ascertain  exactly  the  dif- 
ference between  the  negro  and  Caucasian  constitution.  The  patient  was  a 
negro.  Their  blood  is  relatively  richer  in  carbonic  acid,  and  other  elements 
which  dispose  to  apathy.  In  all  diseases  which  involve  principally  the 
arterial  system  and  its  contents  they  are  disposed  to  stupor.  The  grade  of 
nervous  action  is  relatively  low.  In  them  with  pneumonia,  the  congested 
condition  of  the  pulmonary  capillaries  is  always  deeper,  and  since  the  relief 
of  congestion  is  dependent  on  nervous  power  and  co-efficiency,  it  seems  not 
improbable  that  in  this  case  these  elements — not  so  in  the  case  of  the  white — 
contribute  to  such  a  fatal  termination. 

These  latter  suppositions  are  rather  favoured  by  the  fact  that  the  stimu- 
lating measures  caused  an  immediate  improvement  in  the  sinking  condition, 
so  great  that  we  no  longer  despaired  of  the  patient's  life.  Our  alarm  was 
greatly  diminished,  and  death,  which,  at  first  seemed  imminent,  did  not  take 
place  for  four  hours  afterwards.  Again,  the  chilly  state  of  the  system 
supervened,  and  the  patient  died  without  a  sign  of  distress ;  no  symptoms 
thought  to  be  of  poisoning  were  remarked,  and  no  sign  of  inflammatory  or 
other  malignant  action  was  found  in  any  of  the  vessels.  Indeed  there  had 
been  no  symptoms  to  occasion  a  suspicion  of  such.    The  tumour  was  filled 


1863.]  Browne,  Ligation  of  the  Subclavian.  73 

with  a  dark  but  not  firm  clot.  Would  it  have  been  better  surgery  to  allow 
the  aneurism  to  take  its  course,  or  to  have  endeavoured  the  complete  sup- 
pression of  the  axillary  artery  by  some  mechanical  contrivance?  If  we 
admit  the  doctrine  of  "constitutional  irritation,"  to  what  was  it  attributa- 
ble— to  the  wound,  or  to  the  general  condition  of  the  system  in  a  malarious 
atmosphere  ?  I  briefly  recapitulate  the  antecedents  of  the  operation,  that 
*  each  reader  may  judge  for  himself  whether  they  are  suitable  to  this  doctrine. 
Five  months  before,  "  William"  trying  to  escape  to  Needham  on  the 
entrance  of  the  Union  forces,  was  assailed  by  his  master  with  a  loaded 
pistol,  from  which  four  shots  were  fired.  .  Two  struck  him  on  the  deltoid 
part  of  the  arm,  nearly  on  a  level,  when  the  arm  is  dependent,  with  the 
middle  of  the  axillary  space.  These  felled  him  to  the  ground.  He  was 
raised  and  taken  home.  He  "  had  never  been  sick,"  but  "  for  a  week  after 
receiving  these  shots  he  had  a  fever."  A  physician  washed  the  blood 
away  and  poulticed.  After  that  week,  the  pain  diminished  in  his  shoulder, 
and  he  continued  to  "feel  the  misery  in  his  hand  and  elbow.11  Still  fur- 
ther on  and  up  to  his  visit  to  me,  he  complained  of  a  want  of  power  in  his 
arm,  and  then  it  presented  much  diminished  sensibility  and  power  of  motion, 
being  in  a  dependent  posture.  Tne  patient  received  no  further  treatment 
until  that  period.  Then  I  supposed  that  the  tumour  in  the  axillary  space 
was  the  seat  of  the  ball.  Being  pressed  with  multitudinous  avocations, 
I  dismissed  him  to  come  again.  He  did  so  weeks  afterwards.  The  tumour 
was  now  longer,  I  thought,  than  when  first  seen.  It  was  dense,  and 
though  resilient,  presented  no  signs  of  an  inclosure  of  pus,  or  other  mor- 
bid product  of  inflammatory  or  irritative  action.  At  first,  then,  I  did  not 
think  it  an  aneurism,  but  still  supposed  it  probable  that  it  was  the  seat  of 
the  ball.  The  increasing  lameness  of  the  arm,  and  its  comparative  useless 
state,  counselled  some  operative  interference.  I  very  cautiously  cut  through 
the  skin  upon  the  tumour.  Again  I  carefully  felt,  and  now  detected  obscurely, 
signs  of  pulsation.  I  desisted  at  once.  I  immediately  covered  the  incision 
through  the  skin,  and  told  him  to  call  when  it  was  healed.  I  suppose  I  did 
.  not  then  listen  stethoscopically  for  the  signs  of  aneurism.  If  I  did  not,  I 
can  only  account  for  the  omission  by  supposing  some  sudden  and  imperious 
demand  of  hospital  duty,  constantly  occurring,  drew  me  away  from  the 
spot,  or  what  is  still  more  probable,  and  decidedly  believed  to  have  been 
the  case  by  my  assistants — that  he  was  told  to  wait  until  the  stethoscope 
was  brought,  that  the  examination  might  be  more  private,  it  having  been 
made  in  the  most  public  business  room  of  the  hospital.  It  is  most  proba- 
ble this  was  the  case,  but  if  so,  like  all  of  his  race,  if  so  told,  after  the 
words  were  spoken  all  remembrance  of  them  passed  away.  I  saw  him  next 
about  two  weeks  after,  while  he  was  on  a  visit  to  his  wife ;  and  then  my 
first  act  was  in  accordance  with  the  suspicion  of  aneurism.  I  at  once 
listened  with  the  stethoscope,  and  was  decided.  My  assistants  present,  Drs. 
Muse  and  Clary,  did  the  same  and  agreed.    He  was  then  at  once  told  the 


74  Browne,  Ligation  of  the  Subclavian.  [Jan. 

nature  and  danger  of  the  case,  without  an  operation,  and  the  gravity  with 
it.  That  he  appreciated  either  clearly,  I  cannot  say.  He  only  asked  if  it 
would  hurt  him,  and  was  told  that  he  would  not  feel  the  operation.  I  at 
once  prepared  to  perform  it.  The  table  was  made  ready,  and  the  patient 
placed  upon  it.  I  had  but  two  assistants,  those  named  above.  The  chlo- 
roform was  administered  by  Dr.  Muse.  Shortly  after  coming  under  its 
influence  the  respiratory  movement  intermitted.  Long  accustomed  to  this 
result  in  animals,  it  was  withheld.  For  the  time  being,  the  suspension  was 
complete,  but  there  was  no  confusion.  But  a  few  seconds  had  intervened 
since  he  was  struggling  under  control,  and  the  suspension  of  the  respiratory 
movement  was  so  abrupt,  that  the  administrator  with  his  eyes  on  the  patient's 
face,  his  hand  on  the  radial  artery,  did  not  notice  it  as  soon  as  myself.  His 
tongue  was  at  once  drawn  forward  with  the  forceps  in  my  hand,  and  held 
by  Dr.  Clary.  I  alternately  depressed  and  upheld  at  the  sides  his  chest. 
With  my  left  hand  I  felt  for  the  heart  beat,  and  discerned  it  much  dimin- 
ished and  of  slow  rate.  The  action  on  the  chest  was  continued,  and  the 
suspension  of  the  respiratory  movement  immediately  ended. 

The  pure  chloroform  was  now  withheld,  and  the  patient  made  to  inhale  a 
mixture  of  that  anaesthetic  and  sulphuric  ether.  With  this,  he  soon  after — 
some  vigorous  struggling  attesting  the  complete  return  of  his  bodily  powers 
— again  became  quiescent.  The  operation  was  now  performed.  He  was  but 
lightly  anaesthetized  by  my  direction,  and  on  the  first  cut  squirmed,  strug- 
gled, and  vigorously  mumbled.  Being  held  comparatively  still,  I  continued. 
When  about  half  through  the  operation  he  again  struggled,  but  an  increase 
of  the  quantity  of  the  anaesthetic  again  made  him  quiescent.  Except  the 
incision  through  the  skin,  and  the  division  of  the  muscular  tissue,  all  the 
tissue  gone  through  was  divided  by  the  forceps.  ~No  bloodvessels  of  the 
least  calibre  were  cut.  The  vessel  was  at  least  once  and  a  half  or  twice  as 
deep  as  I  ever  saw  it  in  any  cadaver,  on  which  I  had  previously  performed 
the  operation. 

The  third  division  of  the  artery  was  found  out  of  its  usual  relation ;  it 
was  however  soon  found  and  tied;  my  assistants  having  assured  themselves, 
at  my  suggestion,  that  it  alone  was  ligated.  The  extreme  depth  of  the 
wound  was  owing  to  the  very  remarkable  thickness  of  the  clavicle,  and  the 
more  extreme  bulge  of  the  ribs ;  the  patient  being  one  of  those  barrel 
chested  negroes  sometimes  met  with. 

There  was  no  ground  for  the  suspicion  that  the  least  portion  of  any  other 
tissue  had  been  included  in  the  ligation,  and  the  autopsy  showed  all  but  the 
artery  apart  from  the  ligation.  That  wounds  in  a  malarious  district  are 
more  dangerous,  or  turn  to  a  greater  ratio  of  fatality  among  the  wounded, 
would  be  indeed  a  fact  of  startling  gravity.  In  seeking  an  explanation  of 
such  points,  caution  cannot  be  excessive  ;  otherwise  it  is  gilding  an  edifice 
which  does  not  suit  the  site.  It  has  been  unexpectedly  observed  that  the 
fatality  of  wounds  in  the  fever  districts  of  the  Virginia  peninsula  was  very 
great. 


1863.]  Pile,  Dislocation  reduced  by  Manipulation.  15 

Was  the  inordinate  depth  of  the  wound  a  condition  of  fatality  ?  This 
might  readily  be  the  case  unknown  as  yet  to  us,  a  hitherto  unconsidered 
danger  ?    I  need  hardly  multiply  questions  I  am  unable  to  answer. 

There  is,  however,  one  consideration  which  we  have  long  believed  to  be 
important,  and  which  was  strengthened  by  this  death.  If  the  obliteration 
of  an  artery  and  thereby  the  cure  of  aneurism  by  pressure  be  the  best 
known  mode,  why  should  we  not  deem  it  better  than  ligation  to  imitate 
it  as  near  as  possible,  where  the  ligation  is  impracticable.  How  far 
the  ligation  itself  contributes  to  constitutional  disturbance  we  do  not 
know.  Several  years  since  I  conceived  the  idea  that  pressure  on  the  artery 
,  when  exposed,  by  a  delicate  slip  of  metal,  bent  upon  itself  over  the  artery, 
and  which  merely  flattened  it,  was  a  better  proceeding  than  ligation.  Some 
experiments  made  on  the  arteries  of  animals  proved  it  to  be  correct.  The 
same  is  the  case  in  all  pressure  where  it  is  convenient,  and  I  regret  that 
I  did  not  find  the  first  convenient  in  this  instance. 


Art.  IX. — Dislocation  of  the  Left  Shoulder  reduced  by  Manipulation, 
without  the  Employment  of  Anaesthetics  or  other  Remedies.  By 
Charles  H.  Pile,  M.  D.,  Assist.  Surg.  U.  S.  Navy. 

On  the  morning  of  October  9th,  I  was  called  to  see  a  sailor  suffering 
from  an  injury  of  the  left  shoulder,  produced  by  a  fall  on  deck.  On  exa- 
mining the  injured  part,  I  discovered  a  luxation  of  the  humerus  forward, 
the  head  of  the  bone  forming  a  prominent  tumour  under  the  belly  of  the 
pectoralis  major  muscle ;  the  acromion  process  of  the  scapula  was  promi- 
nent and  well  defined.  I  immediately  proceeded  to  reduction.  I  seated 
the  patient  on  a  low  stool,  flexed  the  forearm  on  the  arm,  elevated  the 
arm  at  an  angle  of  45°  with  the  body,  then  rotating  the  head  of  the  hu- 
merus by  turning  the  arm  backwards  as  far  as  possible,  and  afterwards  sud- 
denly reversing  the  motion  on  carrying  the  injured  extremity  across  the  chest 
towards  the  sound  side,  when  the  head  of  the  bone  slipped  into  the  glenoid 
cavity  with  a  slight  noise.  This  process  for  reducing  dislocations  of  the 
shoulder  was  taught  me  by  my  old  friend  and  preceptor,  Prof.  H.  H. 
Smith,  of  Philadelphia. 

The  advantage  it  possesses  over  the  old  method  is  very  manifest,  since 
instead  of  requiring  a  vast  expense  of  muscular  power  on  the  part  of  the 
surgeon,  it  is  nearly  all  transferred  to  the  muscles  of  the  patient.  In 
flexing  the  forearm  on  the  arm,  the  flexor  muscles  are  relaxed  ;  by  elevating 
and  rotating  the  head  of  the  humerus,  it  is  dislodged  from  the  neck  of  the 
scapula,  and  gradually  forced  upon  the  edge  of  the  glenoid  cavity,  when  the 
supra-spinatus,  deltoid,  and  infra-spinatus  muscles  quickly  draw  it  into  its 
proper  place. 


76    Anderson,  Hemorrhage  following  Extraction  of  a  Tooth.  [Jan.* 


Art.  X. — Hemorrhage  following  the  Extraction  of  a  Tooth.   By  George 
S.  D.  Anderson,  M.  D.,  of  Rapides,  Louisiana. 

The  following  case  of  hemorrhage  consequent  on  the  extraction  of  a 
tooth  came  under  our  observation  some  time  since,  and  we  report  it  because 
it  may  be  considered  as  possessing  some  points  of  interest. 

S          S  ,  a  shingle  maker  and'  house  roofer  by  trade — about  50 

years  of  age,  of  the  bilious-sanguine  temperament,  light  hair,  very  light 
hazel  eyes,  large,  well  formed  and  muscular,  has  been  and  is  a  man  of  dis- 
sipated habits,  but  is  free  from  hereditary  predisposition  to  disease — had  the 
right  upper  cuspid  tooth  extracted  by  us  at  about  12  M.  of  Wednesday,  the 
19th  of  December,  1855.  After  extracting  the  tooth,  we  told  him  to  put 
some  common  salt  into  the  cavity  whence  the  tooth  was  extracted.  He  did 
so,  and  resumed  his  labour,  riving  boards.  He  continued  to  work  till 
night,  lifting  frequently  heavy  bolts  of  timber.  The  hemorrhage  ceased, 
or  nearly  so,  till  about  6  P.  M.,  when  it  recommenced  and  bled  freely  till 
about  5  next  morning,  when  we  were  summoned  in  haste  to  see  him.  We 
found  a  good  many  coagula  of  blood  on  the  hearth,  and  on  the  floor  of  his 
room.  He  had  fallen  into  a  doze  a  short  time  before  our  arrival, 
and  was  sleeping  when  we  entered  the  room.  A  coagulum  of  blood  was 
hanging  out  of  his  mouth,  reaching  to  his  pillow.  He  soon  awoke,  when 
the  clotted  blood  was  removed  from  his  mouth.  The  hemorrhage  was  still 
going  on,  with  no  disposition  to  stop.  The  bystanders  stood  somewhat 
amazed,  being  apprehensive  of  a  fatal  result. 

Such  was  the  case  before  me.  I  could  not  ascertain  with  any  degree  of 
certainty  the  quantity  of  blood  that  had  been  lost,  but  enough  to  cause 
faintness  whenever  he  rose  to  the  sitting  posture.  Under  these  circum- 
stances what  was  to  be  done  to  arrest  the  hemorrhage  ?    Mr.  S  was 

not  of  the  hemorrhagic  diathesis,  and  there  was  no  want  of  coagulability 
in  the  blood,  as  evidenced  by  the  numerous  coagula  lying  on  the  hearth 
before  me.  It  was,  then,  clearly  evident  that  compression  over  the  open 
cavity  for  a  sufficient  length  of  time  for  the  blood  in  it  to  coagulate  would 
arrest  effectually  the  hemorrhage.  We  therefore  put  our  finger  over  it  till 
we  could  get  some  sole-leather,  from  the  flesh  side  of  which  we  had  enough 
scraped  to  form  a  plug.  This  we  put  into  the  alveolar  cavity  whence  the 
tooth  had  been  drawn,  and  continued  to  make  pressure  with  our  finger  for 
near  two  hours,  and  thus  succeeded  in  arresting  the  hemorrhage. 

The  pressure  alone  might  have  sufficed  in  this  case,  and  no  doubt  would, 
but  as  the  leather  possesses  astringent  properties  from  Jhe  tannin  used  in 
tanning  it,  it  is  very  clear  that  it  better  answers  the  indication  than  almost 
anything  else.  Besides,  it  is  an  animal  substance,  and  is  not  likely  to  cre- 
ate inflammation,  as  lint  or  other  vegetable  substance  would  do.  Cobweb, 
fur,  and  other  things  have  been  used  for  the  purpose  of  arresting  hemor- 


1863.]  Owen,  Premature  Delivery. 

rhages  from  incised  and  other  wounds  by  the  vulgar,  and  even  by  physicians 
in  some  instances,  under  the  belief  that  they  have  some  specific  effect  in 
arresting  hemorrhage.  This  is  an  erroneous  opinion,  as  they  are  possessed 
of  no  astringent  properties  whatever.  By  adhering  to  the  edges  of  the 
wound,  they  interrupt  the  flow  of  blood  by  forming  a  coagulum,  which 
closes  the  orifice  and  stops  the  bleeding.  Cobweb  had  been  used  in  the 
case  now  reported,  and  if  pressure  had  been  made  a  sufficient  length  of 
time  it  would  have  answered  every  desirable  purpose.  But  the  substance 
used  by  us  in  this  instance  (and  it  was  originally  suggested  by  another), 
answers  better,  as  it  combines  in  its  action  astringent  properties.  We 
certainly  believe  that  this  would  be  the  best  substance  that  could  be  used 
in  those  cases  of  hemorrhage  following  the  extraction  of  teeth  in  persons 
in  whom  the  hemorrhagic  diathesis  exists,  in  which  there  is  manifest  want 
of  coagulability  in  the  blood.  Dipped  in  a  saturated  solution  of  tannin, 
nothing,  it  appears  to  us,  would  answer  a  better  purpose.  Or,  the  cavity 
might  first  be  injected  with  the  solution,  of  tannin.1 


Art.  XI. — Premature  Delivery,  with  very  rare  Presentation  of  the 
Fcetus.    By  W.  T.  Owen,  M.  D.,  of  Louisville,  Ky. 

I  was  called  to  see  Mrs.  J.,  of  Louisville,  aged  15  years,  primipara,  in 
labour  after  a  seven  and  a  half  months'  pregnancy,  on  the  24th  of  May, 
at  2  o'clock  A.  M.,  and  found  her  with  strong,  frequently  recurring 
labour-pains,  induced  by  a  large  dose  of  castor  oil,  which  she  stated  that 
she  had  taken  on  the  previous  evening.  Os  uteri  slightly  open.  Pre- 
scribed sulph.  morphise  gr.  ss  every  half  hour,  or  pro  re  nata.  Two 
doses  secured  perfect  tranquillity  through  the  remainder  of  the  night,  and 
for  the  next  twenty -four  hours,  when  I  was  called  again,  to  find  her  de- 
cidedly in  labour,  and  the  os  uteri  dilated  to  the  size  of  a  half  sovereign  or 
over ;  the  lips  of  the  os  rigid,  membranes  tense,  uniform  to  the  sense  of 
touch.  Unable  to  distinguish  the  presentation.  Maintained  the  integrity 
of  the  membranes  until  the  anterior  lip  of  the  neck  of  the  uterus  would 
easily  pass  up  behind  the  os  pubis  and  remain,  and  supposed  the  nates  to 
be  the  presenting  part ;  then  ruptured  the  membranes,  and  a  most  inordi- 
nate flow  of  liquor  amnii  passed  off  instantly.  Upon  immediate  examina- 
tion, I  fo and  the  right  side  of  the  foetus  presenting;  the  anterior  surface 
of  the  child  corresponding  to  the  anterior  aspect  of  the  mother;  the  right 
hip  of  the  child  in  the  left  iliac  region,  the  right  shoulder  in  the  right  iliac 

1  [We  must  take  advantage  of  this  opportunity  to  calL  attention  to  the  efficacy 
of  the  persulphate  of  iron  (Monsel's  salt)  as  an  haemostatic.  It  is  undoubtedly 
the  most  efficient  one  we  possess,  and  when  procurable,  it  should  not  be  over- 
looked.— Ed.] 


78 


Taylor,  Placenta  Prsevia. 


[Jan. 


space,  equidistant  from  the  os  uteri  proper.  The  next  pain  was  very- 
severe,  forcing  the  child  down  deep  into  the  pelvis,  with  no  prospect  of 
delivery  in  said  position.  I  demanded  a  consultation  with  Prof.  Miller. 
However,  I  placed  her  immediately  under  the  influence  of  chloroform  car- 
ried to  anaesthesia,  and  the  uterus,  which  hitherto  had  strongly  contracted, 
and  was  now  moulded  to  the  shape  of  its  contents,  relaxed,  and  enabled 
me  to  push  up  the  superior  extremity  sufficiently  to  bring  down  by  its  next 
pain  the  nates ;  and  with  the  second  pain  the  breech  fairly  engaged  within 
the  os,  with  a  foot  and  leg  flexed  on  the  thigh.  I  delivered  her  very 
shortly  after  of  a  living  male  child.  The  head  was  sufficiently  long  in  its 
detention  to  cut  off  the  placental  circulation,  which  I  counterbalanced  in 
my  efforts  at  extraction — my  finger  in  the  child's  mouth  enabling  it  to 
take  four  inspirations  ;  intra-uterine  respiration. 

Having  given  a  concise  account  of  the  prominent  features  of  the  case,  I 
desire  to  make  a  few  observations  by  way  of  synopsis. 

1st.  The  extreme  youth  of  my  patient — scarce  fifteen  years;  the  vagi- 
nal canal,  os  externum  smaller  than  any  accouchee  I  have  ever  known. 
2d.  The  propriety  of  permitting  the  membranes  to  remain  entire,  if  possi- 
ble, until  full  dilatation  of  the  os  takes  place.  This  I  deem  of  the  first 
importance  in  vertex  presentations,  and  a  fortiori  in  nates  and  other  pre- 
ternatural presentations.  3d.  The  value  of  chloroform — in  this  case  most 
signal.  Why  ?  It  produced  relaxation  of  the  uterus  sufficient  to  enable 
me  to  convert  a  most  unusual  and  dangerous  position  into  a  comparatively 
safe  and  not  unusual  one.  At  the  time  of  the  rupture  of  the  membranes, 
when  the  fact  was  clearly  before  me  that  I  had  a  side  presentation,  and  I 
demanded  a  consultation,  my  mind  was  clearly  made  up  that  version  was 
unattainable  on  account  of  the  extreme  smallness  of  the  vaginal  canal  and 
os  externum — that  my  only  chance  was  embryotomy,  and  its  feasibility  for 
the  same  cause  was  a  question.  I  succeeded  without  other  aid.  4th.  The 
inspiration  of  four  full  breaths,  taken  by  the  child  while  its  face  was  im- 
pacted in  the  hollow  of  the  sacrum  ;  intra-uterine  respiration.  5th.  A 
living  child,  well  formed,  uninjured. 


Art.  XII.—  Ca,se  of  Placenta  Prsevia.    By  Wm.  T.  Taylor,  M.  D. 

About  the  beginning  of  September,  1862, 1  was  engaged  to  attend  Mrs. 
Q.,  residing  in  the  20th  ward,  during  her  labour,  which  was  to  occur  in 
October  following. 

For  a  few  months  previous,  she  had  been  troubled  with  frequent,  but 
slight  uterine  hemorrhages,  which  being  attended  with  no  pain,  caused  her 
little  uneasiness,  this  being  her  second  gestation. 

On  the  16th  of  September,  the  flow  was  very  profuse,  and  being  some- 
what alarmed  she  sent  for  me;  it  however  had  ceased  before  my  arrival, 


1863.] 


Davies,  Injury  of  the  Neck. 


79 


Suspecting  it  to  be  a  case  of  placenta  praevia,  yet  requiring  no  interference 
at  that  time,  I  requested  her  to  remain  quiet  for  a  few  days,  and  avoid  any 
exertion. 

There  was  no  recurrence  of  the  hemorrhage  until  September  26th,  when 
it  came  on  very  profusely,  accompanied  with  some  pain. 

On  examination  per  vaginam,  the  os  uteri  was  dilated  to  the  diameter 
of  an  inch,  and  within  the  neck  covering  the  os  completely  was  the  pla- 
centa, bleeding  freely  with  every  pain  ;  indeed  the  hemorrhage  since  morn- 
ing had  been  quite  alarming.  Having  tamponed  the  vagina  I  waited 
patiently  for  an  half  hour,  when  the  pains  being  quite  severe  and  very 
frequent  the  tampon  was  removed.  The  dilatation  had  increased  consider- 
ably ;  again  the  tampon  was  introduced  and  an  hour  was  allowed  to  pass  ; 
when  the  pains  being  very  severe,  and  occurring  more  frequently,  accom- 
panied also  with  some  discharge  of  blood,  in  consequence  of  the  plug  not 
being  accurately  applied,  it  was  again  removed.  The  os  uteri  was  found 
to  be  well  dilated,  and  completely  covered  by  the  placenta. 

Having  gradually  passed  my  hand  Jbetween  it  and  the  posterior  lip  of  the 
uterus,  I  detached  a  portion  of  it,  and  discovered  the  membranes  above ; 
on  rupturing  them  the  hand  and  foot  of  a  small  child  presented.  The 
mother  was  quite  exhausted  by  the  hemorrhage,  and  a  draught  of  brandy 
and  water  was  given  to  her,  when  I  proceeded  to  deliver  her  by  bringing 
down  the  feet  and  body  ;  the  arms  and  head  were  extracted  with  some  little 
delay. 

The  child  appeared  dead ;  but  as  there  was  some  pulsation  in  the  cord, 
and  a  portion  of  the  placenta  still  adhered  to  the  uterus,  by  rolling  it 
gently  from  side  to  side  (as  Marshall  Hall  suggests  to  imitate  respira- 
tion) for  a  few  minutes,  it  began  to  breathe,  and  very  soon  manifested  its 
vitality  by  loud  cries. 

When  it  had  acquired  sufficient  strength,  and  a  good  degree  of  warmth, 
I  tied  the  cord  and  removed  the  placenta.  The  womb  contracted  firmly ; 
the  after-pains  were  very  slight.  The  mother  made  a  rapid  recovery,  and 
her  babe  is  now  quite  vigorous  and  large.  Its  life  is  probably  owing  to 
the  circumstance  that  the  placenta  remained  partially  attached  to  the  uterus 
until  after  its  delivery,  thus  keeping  up  the  connection  with  its  parent 
until  respiration  was  established. 

Deceinber  2d,  1862. 


Art.  XIII.  Case  of  Injury  of  the  Neck.  By  Redfern1  Davies,  M.  D., 
of  Birmingham,  England,  now  acting  Assistant  Surgeon  IT.  S.  A, 
(Brought  before  the  Brodie  Med.  Chirur.  So.,  Frederick  City,  Md.) 

Leverett  Evans,  aged  22  years,  of  small  stature,  and  feeble  build,  was 
wounded  at  the  battle  of  Antietam,  September  17th,  by  a  bullet  entering 


30 


Da  vies,  Injury  of  the  Neck. 


[Jan. 


(his  mouth  being  open)  about  the  middle  of  the  left  anterior  pillar  of  the 
fauces  and  issuing  at  the  back  of  the  neck,  two  inches  from  the  spinous 
process  of  the  second  cervical  vertebra  on  the  left  side. 

A  probe  passed  freely  through  the  two  apertures,  grating  against  bone 
in  its  course. 

He  stated  that  he  had  lost  much  blood,  producing  faintness  for  several 
hours  after  the  receipt  of  the  injury.  Since,  however,  having  been  a  patient 
in  this  Hospital  he  has  done  well,  and  as  usual  was  walking  about  the 
ward  keeping  his  head  as  immovable  as  he  could  up  to  the  morning  of  the 
31st  of  October. 

When  while  lying  down  on  his  bed  and  without  any  known  cause  he- 
morrhage of  a  ''bright  red  colour"  occurred  to  the  amount  of  "  about  one 
wineglass  full;"  this  bleeding  issued  from  both  apertures,  and  continued  but 
for  a  few  minutes,  so  that  when  I  was  in  attendance  upon  him  there  was 
only  some  clotted  blood  to  be  seen  in  his  mouth  and  on  the  back  of  his  neck. 

Another  hemorrhage  occurred  in  the  course  of  two  days,  when  "  about  a 
teaspoonful"  of  blood  was  lost. 

Both  apertures  as  well  as  discharge  from  the  wound  continued  very  good, 
and  his  general  condition,  though  feeble,  was  fair. 

On  November  13th,  shortly  after  eating  his  breakfast,  when  he  appeared 
as  usual,  his  mouth  was  observed  to  be  drawn  towards  the  right  side,  facial 
expression  on  the  left  side  was  gone,  and  on  attempting  to  whistle  his 
breath  escaped  at  the  left  corner  of  his  mouth.  In  an  hour  or  so  he  began 
to  mutter  incoherently  and  deliriously,  and  died  next  day  at  6  A.  M. 

Post-mortem  six  hours  after  death,  Nov.  14. 

Examination  of  parts  involved  in  this  injury  showed  :  a  sloughing  pas- 
sage in  the  bullet  track,  into  which  was  forced,  for  a  distance  of  an  inch,  the 
last  molar  tooth ;  the  adjacent  soft  parts  were  healthy.  Upon  injecting 
the  common  carotid  and  vertebral  arteries  on  both  sides,  the  injection 
passed  readily  and  well  in  all  save  in  the  left  common  carotid  artery  where 
its  progress  was  arrested  firmly  after  passing  for  a  distance  of  about  two 
inches  ;  here  its  termination  was  covered  in  by  an  organized  cul-de-sac,  its 
distal  termination  as  also  its  branches  could  not  be  found. 

Ligamentous  union  and  cartilage  between  the  bodies  of  the  first  and 
second  vertebras  were  gone,  their  opposing  surfaces  being  roughened. 

From  the  foregoing  facts,  I  am  induced  to  believe  that  the  internal  caro- 
tid artery  was  laid  open  by  the  bullet  which  inflicted  the  injury ;  from  the 
consequent  loss  of  blood  which  ensued,  faintness  was  induced.  That  while 
in  this  condition,  a  sufficiently  strong  coagulum  was  produced  to  prevent 
any  further  escape  of  blood ;  and  that  by  the  process  attendant  upon  the 
prolonged  suppuration  (45  days)  the  remainder  of  the  artery  was  disin- 
tegrated and  passed  away  in  the  discharges. 

The  succeeding  hemorrhages  were  caused  by  minute  openings  into  branches 
of  the  external  carotid  artery,  which  were  spontaneously  arrested  as  they 
spontaneously  arose. 


1863.] 


81 


TRANSACTIONS  OF  SOCIETIES. 


Art.  XIY. — Summary  of  the  Transactions  of  the  College  of  Physicians 

of  Philadelphia. 

1861.  Sept.  4.*  Intra-uterine  Hydrocephalus ;  Breech  Presentation; 
Craniotomy ;  Recovery  of  Mother. — Dr.  Corse  related  the  following  case. 

Hydrocephalus,  occurring  during  intra-uterine  life,  is  generally  of  much 
less  interest  than  when  it  occurs  after  birth.  It  is  almost,  if  indeed  not 
always,  dependent  upon  some  malformation  of  the  cranial  contents,  which 
would  properly  place  it  within  the  sphere  of  teratology.  Such  occurrences 
are  exceedingly  rare.  Their  chief  interest  is  to  the  obstetrician,  as  they 
very  generally  dangerously  complicate  labour,  and  render  the  operation  of 
craniotomy  necessary.  This  is  the  case  when  in  labour  some  part  of  the 
head  presents,  but  the  difficulty  and  danger  are  increased  if  the  breech 
comes  down,  as  in  the  present  instance. 

Mrs.  S.  J.,  after  having  given  birth  to  two  fine  perfectly  formed  chil- 
dren, who  are  now  living  and  healthy,  was  taken  in  labour  with  her  third 
child  on  Thursday  morning,  about  5  o'clock.  The  attending  physician 
was  sent  for,  and  arrived  about  9  A.  M.  The  symptoms  not  being  urgent, 
he  left  her  and  returned  several  times  through  the  day.  About  5  P.  M. 
the  body  of  the  infant  was  delivered,  but  the  head  was  retained  in  spite  of 
his  efforts  to  deliver  it.  The  real  nature  of  the  case  was  as  yet  unknown, 
and  the  cause  of  the  delay  was  supposed  to  be  absence  of  uterine  contrac- 
tions. About  8  o'clock  P.  M.  a  neighbouring  physician  was  called,  who 
attempted  the  use  of  forceps.  After  fruitless  efforts  a  third  was  sent  for, 
who,  upon  examination,  proposed  that  I  should  be  joined  to  the  consulta- 
tion. 

Much  time  had  elapsed  in  sending  messages  to  and  fro,  and  it  was  4 
o'clock  next  morning  before  I  got  the  message.  I  was  soon  by  the  patient, 
and  found  the  child  was  in  the  fifth  position  of  the  breech.  Extension  had 
taken  place,  and  the  chin  was  resting  on  the  brim  of  the  pelvis,  at  the  right 
acetabulum.  I  succeeded  in  bringing  it  down  and  rotating  the  head  so  as 
to  bring  the  occiput  to  the  acetabulum  position.  The  long  forceps  were 
then  applied,  and  during  this  process  it  was  discovered  that  the  head  was 
of  enormous  size.  Efforts  were  made  to  diminish  it  by  compression;  but, 
this  being  impossible,  craniotomy  was  agreed  upon.  The  head  being  above 
the  superior  strait,  the  shoulders  of  the  child  completely  occupied  the 
maternal  passage,  and  presented  an  obstacle  to  operating ;  it  was  then 
determined  to  remove  the  body  by  amputation  at  the  neck.  The  head  being 
firmly  secured  in  the  blades  of  the  forceps,  and  held  by  an  assistant,  the  neck 
was  severed.  Sufficient  space  was  now  allowed.  The  operation  consisted 
in  making  an  opening  through  the  soft  parts  under  the  chin,  and  through 

*  This  case  was  unavoidably  omitted  in  the  last  number  of  Transactions  of  the 
College. 

No.  LXXXIX— Jan.  1863.  6 


S2 


Transactions  of  the 


[Jan. 


the  basilar  process  of  the  occipital  bone  into  the  cavity  of  the  cranium  ;  by 
this  means  a  considerable  part  of  the  contents  of  the  cranium  were  removed. 
Compression  at  this  time  by  means  of  the  forceps  caused  the  cranium  to 
collapse,  and  moderate  traction  delivered  the  head.  The  after-birth  was 
removed  by  manual  aid. 

The  patient  had  become  exceedingly  depressed,  partly  by  the  unfavour- 
able prognostications  of  her  numerous  female  friends,  and  partly  by  the 
long  continuance  of  the  labour.  She  soon,  however,  reacted,  and  got  well 
almost  without  an  unpleasant  symptom. 

1862.    May*!.    Dr.  Hunt  reported  the  following 

Remarkable  Case  of  the  Co-existence  of  Tetanus  and  Paralysis. — 
R.  C,  a  boy  aged  16,  was  admitted  into  the  Episcopal  Hospital  on  the 
12th  of  April,  1862.  He  had  been  injured  in  a  rope  factory  by  a  machine 
which  I  personally  inspected  afterwards.  It  is  a  large  wheel,  some  twelve 
feet  in  diameter,  and  eighteen  inches  broad  at  the  circumference.  The 
outer  surface  is  studded  very  thickly  with  polished  iron  spikes,  three  and  a 
half  inches  long,  very  sharp  at  the  points,  and  about  one-fourth  of  an  inch 
thick  at  the  base.  In  fact  it  is  an  immense  circular  comb,  revolved  by 
steam,  and  used  for  the  purpose  of  disentangling  and  layering  hemp. 

While  revolving,  the  machine  requires  a  man  and  an  adept  to  attend.it; 
but  in  this  case  the  proper  personage  was  temporarily  absent,  and  the  boy, 
full  of  ambition,  undertook  the  duty.  He  was  caught,  and  after  being  torn 
by  the  points  of  the  spikes,  was  fairly  impaled  by  three  of  them  entering 
his  cranium.  Luckily,  some  one  near  threw  off  the  belt,  and  the  wheel 
stopped,  but  so  firmly  was  the  boy  fixed,  that  it  took  two  men,  one  to 
support  the  body  and  the  other  to  insert  his  fingers  between  the  spikes,  to 
draw  him  off.  The  person  who  acted  in  the  latter  capacity  told  me  that 
the  boy  was  perfectly  conscious ;  did  not  think  he  was  much  hurt,  and 
wished  to  walk  home  or  to  the  hospital.  His  condition  on  admission  was 
as  follows:  There  were  some  eight  or  ten  large  lacerated  wounds  of  the 
back  of  the  right  hand  and  arm,  the  integument  being  thrown  off  in  flaps, 
exposing  the  tendons,  muscles,  and  superficial  vessels  and  nerves.  These 
wounds  reached  as  high  as  the  elbow,  and  the  distances  between  them 
corresponded  with  the  rows  of  spikes.  There  was  no  fracture  of  the  bones 
of  the  arm  or  laceration  of  the  muscles.  The  next  point  of  injury  was  the 
left  malar  bone,  which  was  fractured  by  one  of  the  spikes,  and  then  the 
frontal  and  parietal  bones  appear  to  have  been  pierced.  There  were  three 
punctured  fractures  of  the  left  side  of  the  cranium,  two  through  the  frontal 
bone  and  one  through  the  parietal.  One  of  the  former  was  at  the  frontal 
protuberance,  the  other  was  an  inch  and  a  quarter  from  the  first,  and  just 
within  the  temporal  ridge.  The  puncture  of  the  parietal  bone  was  on  a 
line  half  way  between  the  other  two,  and  a  little  more  than  an  inch  poste- 
rior to  the  coronal  suture.  We  thus  have  a  tripod  of  spikes  indicated,  upon 
which  the  boy  was  impaled. 

There  were  no  brain  symptoms  whatever  at  the  time  of  admission.  The 
reflected  flaps  of  integument  on  the  arm  were  returned  and  secured  by 
sutures,  and  water  dressings  were  applied  to  the  head  and  face.  This  was 
on  a  Saturday.  The  boy  did  perfectly  well  until  Monday,  when  there  were 
intervals  of  delirium  ;  but  most  of  the  time  he  was  rational,  although  quiet 
and  indisposed  to  talk.  He  continued  thus  until  Wednesday,  when  hemi- 
plegia of  the  right  side  came  on.  On  Thursday  the  patient  was  reported 
to  me  as  very  much  worse.    I  found  him  unable  to  speak  ;  when  he  made 


1863.]     College  op  Physicians  of  Philadelphia.  83 

the  attempt,  he  did  nothing  but  mutter.  He  was,  however,  conscious, 
when  aroused,  his  eye  having  an  intelligent  expression,  not  according  with 
his  inability  to  speak.  On  trying  to  open  the  mouth  to  protrude  the 
tongue,  I  found  that  he  could  not  use  his  jaws  properly,  and  was  not  able 
to  separate  them  more  than  half  an  inch.  The  inability  was  greater  upon 
the  left  side  than  upon  the  right,  the  paralysis  of  which  continued  unchanged. 

So  preoccupied  was  my  mind  with  the  idea  of  compression  that  tetanus 
did  not  immediately  occur  to  me.  A  consultation  was  ordered  at  4  o'clock 
Thursday  afternoon.  On  my  way  home,  in  thinking  of  the  anomalies  of 
the  case,  the  question  arose,  "Has  this  boy  tetanus  and  paralysis  together, 
and  is  one  condition  influencing  the  other?"  Drs.  Kenderdine  and  R.  P. 
Thomas  met  in  consultation  at  the  time  proposed,  when  my  suspicions  were 
fully  confirmed.  Well  marked  trismus,  the  very  characteristic  risus  sardo- 
nicus,  and  hard  abdominal  muscles,  showed  unmistakably  the  invasion  of 
tetanus.  At  the  same  time  the  paralysis  of  the  right  side  continued,  and 
although  perfect  as  to  the  arm,  the  patient  once  in  a  while  moved  the  right 
leg,  but  apparently  had  no  voluntary  power  over  it.  The  rectum  and 
bladder  were  also  paralyzed,  and  from  this  time  until  the  termination  of 
the  case,  the  feces  and  urine  were  discharged  involuntarily.  It  was  con- 
cluded not  to  trephine.  The  sutures  were  removed  from  the  arm  wounds, 
and  warm  water  dressings  applied.  The  patient  was  also  given  chloroform 
gtt.  xx,  fluid  ext.  of  conium  gtt.  x,  every  two  hours.  Under  this  treat- 
ment he  became  much  more  quiet.  On  Friday  the  tetanus  was  most  tho- 
roughly confirmed,  by  a  remarkable  combination  of  empros  and  pleuros- 
thotonos,  that  is,  while  there  was  a  forward  bending,  the  body  at  the  same 
time  was  arched  towards  the  left,  as  though  the  paralyzed  side  had  no 
power  of  resistance.  Throughout  Saturday  the  symptoms  continued 
unchanged,  but  on  Sunday  the  boy  became  entirely  unconscious,  and  died 
on  Monday  morning,  on  the  10th  day  from  the  injury. 

Post-mortem. — The  three  punctured  fractures  of  the  cranium — at  the 
points  before  indicated — were  as  clean  on  the  external  surface  of  the  bone 
as  though  made  by  a  sharp  cutting  punch.  No  fissures  radiated  from  them. 
Small  rough  fragments  of  the  internal  table  projected  inwards  from  the 
margins  of  the  holes,  at  which  they  maintained  their  connection  with  the 
sound  bone.  One  of  these  was  at  least  a  half  inch  in  length,  and  was  con- 
nected with  the  fracture  of  the  frontal  protuberance.  The  membranes  and 
brain  were  lacerated  at  points  corresponding  with  the  fractures.  The  right 
anterior  lobe  was  the  seat  of  a  large  abscess,  and  this  lobe  was  more  lace- 
rated than  the  middle  one.  There  was  no  particular  congestion  or  inflam- 
mation of  the  base  and  medulla.  The  spinal  cord  was  not  examined.  The 
wounds  of  the  arm  appeared  to  be  in  good  condition.  An  abscess  had 
formed  about  the  left  knee  joint.  The  other  parts  of  the  body  were  per- 
fectly normal. 

Remarks. — Had  the  tetanus  here  a  peripheral  or  central  origin  ?  In 
"Curling  on  Tetanus,"  I  find  a  table  of  128  cases,  of  which  110  had  the 
original  wound  on  some  part  of  the  extremities,  and  69  of  these  either  in 
the  hands  or  feet;  5  only  had  wounds  of  the  head.  The  lacerated  wounds 
of  the  arm  in  my  case  were  of  the  very  kinds  that  are  supposed  to  be  more 
fruitful  of  tetanus  than  others. 

Did  the  two  conditions  of  tetanus  and  paralysis  have  any  influence  on 
each  other  ?  Was  there  a  cross  action  here  of  any  kind  ?  I  find  two  cases 
which  may  be  considered  as  having  some  bearing  on  these  points.  One  in 
Curling:   "A  boy  received  two  shots  in  the  spine;  immediate  paralysis 


84 


Transactions  or  the 


[Jan. 


of  the  parte  below  followed.  In  seven  days  tetanus  came  on  in  the  form 
of  opisthotonos.  Laudanum  was  given,  in  drachm  doses,  every  half  hour 
during  the  night;  and  the' next  day,  caustic  potash  was  applied  along  the 
whole  length  of  the  spine.  There  was  a  mitigation  of  the  paroxysms;  the 
patient  slept  and  awoke  free  from  the  tetanic  symptoms,  but  the  paralysis 
of  the  lower  extremities  and  of  the  bladder  remained.  Sensation  remained 
perfect." 

In  the  case  just  reported  both  sensation  and  motion  were  affected. 

In  "Longuiore  on  Gunshot  Wounds,"  a  case  is  spoken  of  thus:  "M. 
Baudens  extracted,  with  an  elevator  supplied  with  a  canula,  a  ball  which 
had  lodged  in  the  eleventh  dorsal  vertebra,  and  was  causing  compression 
and  complete  paraplegia.  The  paralysis  disappeared  immediately  after  the 
extraction  of  the  bullet,  but  tetanus  came  on  four  days  afterwards,  and 
proved  speedily  fatal."  In  both  these  cases  there  was  direct  injury  to  the 
spine,  and  there  must  have  been  much  more  laceration  of  tissue  than  was 
made  through  the  integuments  of  the  scalp  in  my  case.  In  fact  the  scalp 
can  scarcely  be  said  to  have  been  lacerated,  but  rather  perforated  by  the 
polished  spikes. 

With  the  case  before  us,  we  have  then  three  cases  in  which  paralysis  and 
tetanus  coexisted.  Doubtless  there  are  others,  but  I  have  not  been  able  to 
find  them. 

Why,  when  the  intelligence  of  this  patient  was  good,  was  he  unable  to 
speak,  but  could  only  give  utterance  to  moaning  and  guttural  sounds? 
His  tongue  was  not  paralyzed.  There  was  nothing  the  matter  with  the 
base  of  the  brain.  The  hearing  and  sight  appeared  to  be  good;  there  was 
no  strabismus.  Patients  with  trismus — at  least  all  I  have  seen — can  speak, 
although  low,  yet  perfectly  distinct.  Is  the  explanation  to  be  found  in  the 
cerebral  wounds  interfering  with  the  will  and  intellect?  It  was  not  owing 
to  a  stupefied  condition  that  the  patient  did  not  speak,  for  it  was  two  days 
before  coma  came  on  that  he  lost  the  power  of  articulating,  and  made  his 
wants  known  by  motions  with  his  left  hand  and  by  his  eyes. 

Surgically,  the  case  is  of  great  interest.  Should  we  have  trephined  this 
boy  over  the  three  fractures?  Does  not  the  post-mortem  show  that  we 
should,  in  all  probability,  have  added  one,  more  case  to  the  long  list  which 
has  almost  abolished  the  trephine  from  the  surgical  armamentarium  ?  The 
calvaria  has  been  preserved,  and  is  a  rare  specimen  of  punctured  fracture, 
with  depression  of  the  internal  table.1 

Nov.  5.  Colloid  Cancer  of  the  Omentum,  Mesentery,  Sc. ;  Scirrhus 
of  the  Stomach  and  Uterus;  Colloid  of  the  Ovaries. — Dr.  Levick  exhi- 
bited a  specimen  of  cancer,  and  made  the  following  remarks  respecting  it : 

Mrs.   ,  a  lady  aged  59,  had  carefully  nursed  her  husband  through  a 

long  and  fatal  illness.  During  this  time,  which  extended  over  a  period  of 
four  years,  her  health  had  been  good  for  the  most  part,  excepting  some 
little  discomfort  after  eating,  which  was  attributed  to  dyspepsia.  There 
was  also  at  the  same  time  a  tendency  to  constipation  of  the  bowels.  To 
relieve  these  symptoms  she  took  small  doses  of  blue  mass,  but  without  any 
appreciable  benefit.  These  symptoms  gradually  increased,  but  she  was  able 
to  attend  to  her  domestic  duties,  and  to  go  out  daily  until  «the  early  part 
of  August,  1862,  when  Dr.  Levick  was  first  called  to  see  her.  He  found 
her  in  bed,  suffering  from  pain  in  the  abdomen,  obstinate  constipation, 
nausea  and  vomiting,  the  stomach  rejecting  almost  everything  taken  into 


1  The  specimen  was  exhibited. 


1863.]     College  of  Physicians  of  Philadelphia.  85 


it.  Careful  inspection  revealed  the  existence  of  a  hard  tumour  in  the  epi- 
gastrium, extending  toward  the  right  hypochondrium.  The  abdomen  was 
prominent  and  very  tympanitic.  The  patient  was  somewhat  relieved  by 
the  use  of  a  turpentine  enema,  and  the  subsequent  use  of  anodynes.  The 
relief  was  but  temporary,  and  the  constipation  and  vomiting  increased  to  a 
most  distressing  degree,  large  quantities  of  a  dark  coffee-grounds  substance 
being  thrown  up  toward  the  last  of  her  illness.  For  more  than  a  fortnight 
before  her  death  she  positively  refused  to  take  nourishment  of  any  kind, 
and  none  passed  her  lips.  In  view  of  the  epigastric  tumour,  and  the  symp- 
toms before  named,  cancer  of  the  stomach  and  intestines  was  at  once  diag- 
nosticated.   She  died  October  19,  1862. 

The  autopsy  was  made  three  days  subsequently.  Exterior.  Emaciation 
extreme.  Abdomen.  On  opening  the  abdomen  a  large  quantity  of  serous 
fluid  of  a  dark  yellow  colour  escaped.  As  soon  as  this  had  all  been  re- 
moved, the  abdominal  viscera  were  found  to  be  covered  with  a  gelatinous 
substance,  of  the  colour  and  consistence  of  calves-foot  jelly,  or  in  some 
places  a  few  shades  darker,  like  gum  copal.  The  omentum,  as  may  be 
seen,  is  entirely  converted  into,  or  replaced  by  this  jelly-like  material ;  it  is 
in  many  places  more  than  half  an  inch  thick,  and  is  heavy ;  the  locular  or 
honey-comb  structure  containing  the  gelatinous  ingredient  is  beautifully 
apparent.  The  mesentery,  the  inner  wall  of  the  abdomen,  the  under  sur- 
face of  the  diaphragm,  and  the  peritoneal  coat  of  the  bowels,  were  all  co- 
vered with  the  same  deposit.  The  same  was  the  case  with  the  peritoneal 
covering  of  the  liver,  the  spleen,  and  the  kidneys  ;  but  what  is  interesting 
to  note,  in  none  of  these  viscera  had  the  colloid  cancer  invaded  the  paren- 
chymatous structure.  The  liver  was  in  the  contracted  stage  of  cirrhosis, 
but  entirely  free  from  cancerous  deposit.  The  spleen  is  of  the  usual  size, 
and,  excepting  its  peritoneal  covering,  unaffected.  So  too  with  the  kidneys, 
which,  though  buried  as  it  were  in  the  soft  gelatinous  matter,  were  entirely 
healthy  in  their  structure.  The  stomach,  as  may  be  seen,  is  greatly  thick- 
ened, is  hard,  and  the  pylorus  the  seat  of  scirrhous  deposit.  The  uterus 
and  its  appendages  present  some  points  of  interest.  The  ovaries  are 
the  seat  of  colloid  cancer,  while  in  the  fundus  and  body  of  the  uterus  are 
two  or  three  tumours,  hard,  and  evidently  of  the  scirrhous  form  of  cancer. 
The  intestines  were  contracted  to  the  size,  in  some  places,  of  a  goose-quill. 
The  specimen  was  removed  from  the  body  a  fortnight  since,  and  by  mace- 
ration in  alcohol  has  lost  its  yellow  colour. 

The  thoracic  viscera  were  entirely  healthy.  Dr.  L.  remarked  that  the 
specimen  before  the  college  was  especially  interesting  to  him  from  the  fact 
that  the  two  forms  of  cancer,  scirrhus  and  colloid,  were  found  associated  as 
they  were  in  this  instance,  thus  establishing  the  close  relationship  which 
exists  between  them,  an  identity  which  had  been  questioned  by  some  writers 
on  colloid  cancer.  Especially  was  this  shown  in  the  appearances  presented 
I  by  the  uterus  and  ovaries  :  the  former,  as  had  been  already  noticed,  being 
the  seat  of  scirrhous  tumours  ;  while  the  latter  was  exclusively  that  of  col- 
loid cancer. 

Cases  of  Stone  in  the  Bladder.  By  Dr.  Gilbert. — The  following  cases 
of  calculus  vesicas,  in  which  removal  was  effected  by  operation,  are  respect- 
fully submitted  to  the  college.  They  embrace  all  the  cases  operated  upon 
by  the  writer,  and  are  interesting  mainly  in  view  of  the  advanced  age  of  the 
patients  : — 

Case  1.  Amy,  a  coloured  woman,  aged  sixty-five  years.    Operation  was 


SG 


Transactions  of  the 


[Jan. 


performed  by  section  of  the  urethra,  in  1851,  at  Gettysburg,  Pa.,  assisted 
by  H.  S.  Huber,  M.  D.  The  stone  was  large,  and  had  to  be  broken  into 
fragments  before  its  extraction.  These  together  weighed  two  ounces,  and 
proved  to  be  of  the  triple  phosphate  variety.  The  patient  recovered,  and 
lived  until  1854,  entirely  free  from  symptoms  of  calculus. 

Case  2.  Mrs.  S.  G.,  of  Brown  Street,  Philadelphia,  aged  seventy-one 
years.  The  operation  was  performed  in  the  same  manner,  on  March  1, 
1854,  assisted  by  Drs.  Bird,  W.  K.  Gilbert,  and  Messrs.  (now  doctors) 
North  and  Barker.  A  light  coloured  lithic  acid  calculus,  weighing  six 
drachms,  was  extracted.    The  patient  recovered. 

Case  3.  Mr.  ,  aged  fifty-one  years,  of  Martinsburg,  Bedford  County, 

Pa.  The  usual  lateral  operation  was  performed,  in  which  I  was  assisted 
by  Drs.  Getty  and  Bloom,  of  the  same  place,  in  June,  1853.  Fragments 
of  phosphatic  calculi,  weighing  two  and  a  half  drachms,  were  removed. 
This  broken  condition  of  the  stone  was  the  result  of  a  previous  attempt,  by 
another  surgeon,  to  remove  it  by  the  operation  of  crushing.  The  patient 
recovered. 

Case  4.  Mr.  ,  aged  fifty-two  years,  presented  himself  at  the  clinic 

of  the  Pennsylvania  College,  in  November,  1853,  with  symptoms  of  stone. 
Being  unwilling  to  submit  to  the  operation  by  incision,  the  stone  was 
crushed  at  several  sittings,  and  large  quantities  of  phosphatic  calculus  were 
removed.  The  bladder  became  so  irritable,  however,  that  the  patient  re- 
fused all  further  efforts,  and  left  the  college  before  the  organ  was  entirely 
relieved  of  its  irritating  contents.  I  heard  several  years  subsequently  that 
his  sufferings  were  greatly  diminished,  so  that  he  did  not  desire  any  further 
operative  procedures. 

Case  5.  I.  McC,  Esq.,  aged  seventy-eight  years,  of  Christian  Street,  in 
this  city,  requested  me  to  visit  him,  in  August,  1861.  I  found  him  suffering 
severely  from  symptoms  of  stone.  A  sound  was  introduced,  which  imme- 
diately enabled  me  to  declare  the  existence  of  calculus.  The  lateral  opera- 
tion was  performed  in  the  ordinary  manner,  on  the  28th  of  the  same  month, 
in  which  I  was  assisted  by  Drs.  J.  H.  B.  McClellan,  R.  Levis,  A.  H.  Fish, 
and  W.  K.  Gilbert.  Two  calculi,  weighing  90  and  100  grains  respectively, 
were  removed.  These  were  principally  phosphatic,  formed  around  nuclei 
of  dark  uric  acid  calculi,  which  were  exposed  in  each  by  friction  of  the  sur- 
faces in  contact.  This  patient  was  unusually  corpulent,  being  of  middling 
stature,  yet  weighing  two  hundred  and  forty  pounds.-  The  perineum  con- 
sequently was  unusually  deep.  Discharged  cured  October  11th,  and  is  now 
living. 

Case  6.  Was  called  to  L.  F.  S.,  Esq.,  of  Keyport,  Monmouth  County, 
New  Jersey.  This  patient,  aged  eighty-one  years  and  two  and  a  half 
months,  had  had  symptoms  of  irritation  of  the  bladder  for  a  number  of  years, 
which  were  borne  with  but  slight  inconvenience.  On  the  9th  of  August 
last  he  rode  in  a  wagon  without  springs  to  his  farm,  six  miles  from  his 
place  of  residence.  The  violent  jolting  over  a  rough  road  gave  rise,  sud- 
denly, to  the  most  excruciating  pains  in  the  region  of  the  bladder.  His 
physician,  Dr.  B.  H.  Porter,  was  called,  and,  suspecting  stone,  sounded 
him,  and  found  his  diagnosis  correct.  I  was  requested  to  visit  the  patient 
and  perforin  the  operation,  which  was  done  on  the  13th  day  of  August, 
assisted  by  Drs.  Porter,  Dayton,  Shackelton,  and  Croft.  The  lateral  inci- 
sion having  been  made,  the  stone  was  grasped  ;  but  owing  to  its  large  size, 
the  right  lobe  of  the  prostate  gland  had  to  be  incised  also  before  it  could 
be  extracted.    The  stone  is  of  the  fawn-coloured  lithic  acid  variety,  oval  in 


» 


1863.]     College  op  Physicians  op  Philadelphia.  8? 


form,  surface  studded  with  large  tubercular  elevations,  and  weighs  seventeen 
drachms  and  two  scruples.  One  side  of  this  stone  was  evidently  attached 
to  the  bladder,  and  became  detached  during  the  ride  on  the  9th  in  the  rough 
wagon. 

The  patient  bore  the  operation  well ;  the  loss  of  blood  did  not  exceed 
four  ounces ;  and  he  expressed  himself  quite  comfortable,  until  the  urine 
began  to  flow  through  the  wound. 

Dr.  B.  H.  Porter  took  charge  of  the  patient,  and  directed  the  after  treat- 
ment. His  almost  daily  reports  for  the  first  twenty  clays  were  so  favour- 
able that  there  was  every  reason  to  believe  that  recovery  was  certain.  At 
this  stage  of  the  case,  however,  Dr.  Porter  became  indisposed,  and  the 
patient  was  without  any  medical  attendant,  until  Dr.  Dayton,  of  Middle- 
town  Point,  was  sent  for.  A  very  decided  change,  of  an  unfavourable 
character,  had  occurred,  and  the  patient  gradually  became  more  feeble,  and 
expired  on  the  thirtieth  day  after  the  operation.  A  son  of  the  deceased, 
who  is  a  clergyman  in  the  Dutch  Reformed  Church,  gave  me  the  follow- 
ing statement  incidentally  in  a  letter,  written  four  weeks  after  his  father's 
decease : — 

"He  appeared  to  be  doing  well  until  the  latter  part  of  the  third  week  • 
after  the  operation.  His  appetite  was  good,  and  he  was  at  times  cheerful. 
His  bowels  continued  obstinately  costive,  and  Dr.  Porter  commenced  admi- 
nistering small  doses  of  senna  every  hour,  without  effect.  When  Dr. 
Dayton  was  called  in,  he  prescribed  a  wineglass  of  salts  and  senna  every 
two  or  three  hours,  until  it  operated.  This  commenced  next  day,  and  be- 
came excessive,  so  that  we  had  difficulty  in  arresting  it,  and  did  not  finally 
until  about  noon  next  day.  From  this  time  he  lost  all  appetite  and  began 
to  sink,  and  so  continued  gradually  until  the  closing  scene,  four  days  after- 
wards." 

From  the  reported  condition  of  this  patient  for  the  first  three  weeks  after 
the  operation  it  is  fair  to  say  that  it  was  successful,  so  far  as  the  operation 
is  concerned.  In  all  the  male  cases  here  reported,  chloroform  and  ether, 
mixed  in  proportions  adapted  to  the  strength  of  the  patients,  were  used  to 
full  anaesthesia.  In  none  of  the  cases  was  there  any  arterial  bleeding, 
except  a  trifling  amount  from  the  transverse  perineal  artery,  which,  with 
the  venous,  in  no  case  exceeded  four  ounces. 

It  may  be  observed  that  the  two  latter  cases  rank  very  high  amongst  the 
extreme  in  age  of  all  reported  cases  of  lithotomy.  Chief  Justice  Marshall, 
operated  for  by  Dr.  Physick,  has  been  considered  the  most  aged  person  suc- 
cessfully operated  on  in  this  country.  By  reference  to  the  memoir  of  Dr. 
Physick,  by  Dr.  Randolph,  it  appears  that  Judge  Marshall  was  seventy-six 
years  old  when  the  operation  was  performed,  whereas  the  ages  of  the  sub- 
jects of  the  last  two  cases  here  reported  were  seventy -eight  years  and 
eighty-one  years  and  two  and  a  half  months  respectively. 

Dec.  3.  Hypodermic  Injections  of  Sulphate  of  Morphia  used  daily  for 
five  months,  twice  daily  for  three  months,  and  three  times  daily  for  six 
weeks,  with  great  relief  to  the  patient,  and  with  no  unpleasan  t  sequelae. — 
Dr.  Levick  remarked  that  the  Fellows  of  the  College  were  doubtless  fami- 
liar with  the  very  interesting  paper  of  Mr.  George  Hunter,  of  St.  George's 
Hospital,  London,  published  in  the  Medical  Times  and  Gazette  of  Sep- 
tember 10,  1859/  in  which  he  had  called  the  attention  of  the  profession  to 

1  See  number  of  this  Journal  for  Jan.  1860,  pp.  238-242. 


S3 


Transactions  of  the 


[Jan. 


a  somewhat  novel  mode  of  treatment — that  of  injecting  medicated  solutions 
into  the  subcutaneous  tissue,  the  hypodermic  or  subcutaneous  injection,  as 
it  is  called.  Allusion  had  previously  been  made  to  this  subject  by  Dr. 
Alexander  Wood,  but  Mr.  Hunter  had  gone  elaborately  into  the  subject, 
and  given  us  a  paper  detailing  the  results  of  various  cases,  in  which  the 
subcutaneous  injection  of  the  solution  of  acetate  of  morphia  was  resorted 
to  with  great  relief  to  the  patients.  He  does  not  limit  its  application  to 
the  alleviation  of  local  pain,  but  reports  cases  of  delirium  tremens,  mania, 
puerperal  mania,  wakefulness,  chorea,  tetanus,  and  sciatica,  all  of  which 
were  more  or  less  benefited  by  its  use.  Since  his  paper  was  published  others 
of  a  similar  character  have  been  issued,  confirmatory  of  his  statement ;  and 
very  recently  it  has  even  been  proposed  to  resort  to  the  subcutaneous  injection 
of  solution  of  quinia  in  the  treatment  of  dangerous  forms  of  miasmatic 
fever.  Influenced  by  the  statements  before  referred  to,  Dr.  L.,  two  years 
ago,  had  recourse  to  the  hypodermic  injection  of  solution  of  morphia  (Ma- 
gendie's  solution)  in  several  obstinate  cases  of  neuralgia,  while  on  duty  in 
the  Pennsylvania  Hospital,  the  result  of  which  was  a  temporary,  and,  in 
some  instances,  a  permanent  relief  to  the  patients.  The  only  inconvenience 
experienced  in  any  of  these  cases  was  the  occasional  occurrence  of  severe 
nausea,  which,  with  the  formation  of  abscesses  in  the  cellular  tissue,  is 
alluded  to  by  Hunter"  as  sometimes  following  the  injection.  The  first  of 
these  inconveniences,  as  he  justly  remarks,  cannot  be  urged  as  a  reason  for 
its  relinquishment,  as  the  same  result  will  often  follow  the  administration 
of  opium  by  the  mouth.  In  these  instances,  as  in  that  which  follows,  the 
instrument  used  was  made  in  this  city.  It  is  of  gutta  percha,  its  maximum 
capacity  twenty-eight  minims.  It  has  a  fine,  silver  tube  about  two  inches 
long,  terminating  in  a  pen-like  point,  so  fashioned  as  to  readily  penetrate 
the  skin.  To  use  it,  the  skin  is  pinched  up,  the  point  of  the  tube  is  cau- 
tiously introduced,  just  far  enough  to  prevent  any  loss  of  the  fluid,  the 
liquid  thrown  into  the  tissue,  and  the  instrument  carefully  withdrawn.  The 
part  immediately  becomes  white  and  puckered,  but  the  operation,  if  properly 
performed,  is  an  almost  painless  one. 

Dr.  Levick  now  begged  leave  to  call  the  attention  of  the  College  to  a  case 
lately  under  his  medical  care,  in  which,  after  the  usual  modes  of  treatment 
had  signally  failed,  the  hypodermic  use  of  the  solution  of  morphia  had  been 
resorted  to  for  the  relief  of  intense  pain,  apparently  of  a  neuralgic  charac- 
ter, to  the  great  temporary  relief  of  the  patient,  and  in  which  this  mode  of 
medication  had  been  resorted  to  daily  for  five  months. 

The  leading  incidents  of  the  case  were  as  follows  :  a  highly 

intelligent  gentleman,  well  known  to  many  Fellows  of  the  College,  had 
three  years  before  suffered  from  an  attack  of  myelitis,  with  paralysis  of  the 
lower  extremities,  referred  to  injuries  received  by  a  fall.  From  this  illness 
he  had  recovered  to  such  an  extent  as  to  resume  his  usual  engagements, 
walking  to  and  from  his  place  of  business  without  difficulty. 

In  the  early  part  of  December,  1861,  he  began  to  experience  sharp,  shoot- 
ing pains  near  the  hip,  following  the  course  of  the  sciatic  nerve,  and  extend- 
ing to  the  calf  of  the  leg.  These  pains,  which  at  first  were  slight,  gradually 
increased  in  severity,  and  after  a  few  days  Dr.  L.  was  for  the  first  time 
called  on  to  visit  him.  The  phenomena  presented  were  those  of  intense 
neuralgia,  with  the  usual  absence  of  fever  or  other  constitutional  disturb- 
ance. The  previous  history  of  the  patient  was  such  as  to  induce  the  sus- 
picion that  there  might  be  organic  disease  at  the  root  of  the  nerve,  but  at 
this  time  and  later  careful  investigation  failed  to  detect  this,  the  possible 


1863.]     College  or  Physicians  of  Philadelphia.  89 

existence  of  which  was,  however,  never  lost  sight  of  in  the  subsequent 
treatment  of  the  case.  The  pill  of  carbonate  of  iron,  with  small  closes  of 
extract  of  belladonna,  and  extract  of  nux  vomica,  were  prescribed  and  taken 
for  a  fortnight  or  more  without  any  benefit.  As  the  attacks  were  some- 
what paroxysmal,  sulphate  of  quinia,  in  full,  anti-periodic  doses,  was  next 
resorted  to,  but  with  no  appreciable  advantage.  In  fact,  from  this  time 
until  the  early  part  of  January,  1862,  there  was  a  steady  increase  of  the 
patient's  sufferings.  Dr.  L.  remarked  that  in  the  whole  course  of  his  prac- 
tice he  had  never  witnessed  such  long-continued  suffering.  The  pain  had 
lost  much  of  its  paroxysmal  character ;  its  intensity  was  such  as  to  prevent 
sleep,  so  that  the  patient  spent  most  of  his  nights  in  his  chair.  This  loss 
of  sleep  and  protracted  pain  had  seriously  affected  his  general  health  ;  he 
had  lost  flesh,  and  his  nervous  system  had  become  so  enfeebled  that  he  was 
unable  to  attend  to  business ;  even  the  effort  to  write  his  name,  or  the 
slightest  mental  exertion,  was  attended  with  an  increase  of  suffering.  Up 
to  this  time  he  had  used  successively  various  narcotic  and  other  remedies. 
The  extract  of  belladonna,  by  pill  and  by  suppository,  the  external  and  in- 
ternal use  of  aconite,  extract  of  hyoscyamus,  morphia  in  large  and  repeated 
doses  by  the  mouth,  laudanum  enemata  (TO  drops),  and  the  sulphate  of 
morphia  in  grain  doses  endermically,  had  each  been  tried,  but  unavailingly, 
as  the  discouraged  patient  himself  said,  "with  little  more  effect  than  so 
much  water."  After  this  Dr.  L.  determined  to  try  the  subcutaneous  injec- 
tion, and  with  this  view  introduced  fifteen  minims  of  the  solution  of  sulphate 
of  morphia  (Magenclie's  solution  gr.  xyj  to  fjj)  into  the  tissue  of  the 
affected  thigh.  The  relief  afforded  was  prompt  and  decided,  and  the  patient, 
for  the  first  time  for  several  weeks,  passed  a  comfortable  night.  The  pain, 
however,  recurred  next  morning,  and  continued  during  the  day  ;  the  injec- 
tion was  repeated  next  night,  and  with  the  same  good  effect.  In  this  way 
it  was  repeated  night  after  night,  the  dose  gradually  increased  until  it 
reached  the  capacity  of  the  syringe,  twenty-eight  minims.  Dr.  L.  remarked 
that  the  temporary  relief  thus  afforded  was  almost  magical.  Frequently  on 
his  evening  visit  he  would  find  his  patient  in  an  agony  of  suffering,  and 
five  minutes  after  giving  the  injection,  would  leave  him  composed  quietly 
for  the  night. 

During  this  time  measures  for  the  permanent  relief  of  the  patient  were 
not  neglected.  In  the  early  part  of  February,  the  injection  was  given  twice 
daily,  the  second  dose  about  twenty  minims  at  1  o'clock  P.  M.,  and,  not  to 
weary  the  College  by  unnecessary  details,  after  this  all  other  modes  of 
medication  were  abandoned  and  the  hypodermic  injection  solely  relied  on. 
In  the  latter  part  of  February,  a  third  injection  daily  was  given  at  about 
five  o'clock  in  the  morning,  the  effect  of  the  evening's  close  beginning  to 
pass  off  by  that  time.  Twenty  minims  were  given  at  this  time.  To  reca- 
pitulate, from  the  early  part  of  January  to  the  middle  of  June,  the  injection 
was  used  every  night ;  from  the  early  part  of  February  to  the  same  time  in 
May,  twice  daily ;  and  from  the  latter  part  of  February  to  the  middle  of 
April,  three  times  daily.  During  this  time  no  unpleasant  head  symptoms 
occurred.  On  the  contrary,  a  marked  improvement  of  the  nervous  system 
was  evident,  and  the  patient  gradually  engaged  in  pursuits  requiring  increas- 
ing mental  efforts.  As  this  improvement  took  place,  the  early  morning 
and  the  mid-day  injections  were  gradually  omitted,  while  that  at  night  was 
continued  as  before.  An  attempt  was  several  times  made  to  inject  in  other 
parts  of  the  body  than  the  affected  thigh,  but  this  was  not  satisfactory  to 
the  patient,  and  with,  perhaps,  three  or  four  exceptions,  the  injections  were 


90     Transactions  of  the  College  of  Physicians.  [Jan. 

all  made  in  the  right  thigh.  That  this  mode  of  medicating  was  not  a  very 
painful  one,  may  be  inferred  from  the  fact  that  it  was  at  the  earnest  solici- 
tation of  the  patient  himself  that  other  modes  were  abandoned,  and  that 
the  third  daily  injection  was  given  him. 

As  the  mild  weather  approached,  the  invalid  went  out  daily  to  drive, 
spent  some  days  in  the  country,  and  in  June  went  to  the  seaside  where, 
as  his  health  improved,  the  remedy  was  entirely  withdrawn.  To  do  this 
was  no  easy  matter.  The  relief  afforded  had  been  so  great  that  the  patient 
dreaded  its  abandonment,  and  this  last  was  only  effected  by  the  cautious 
management  of  his  devoted  nurse,  to  whom  its  administration  had  for  some 
months  been  intrusted.  It  was,  however,  successfully  accomplished  by  the 
substitution  of  water,  drop  by  drop,  for  the  morphia  solution.  After  a 
brief  residence  at  the  seaside,  the  patient  returned  to  the  city,  gradually 
resumed  his  business  engagements,  and  remained  in  good  health  during  the 
summer  and  autumnal  months.  During  the  recent  cold  weather  there  had 
been  some  return  of  pain,  but  not  such  as  to  confine  him  to  the  house. 

Dr.  L.  remarked,  that  it  would  be  observed  that  in  this  case  no  claim 
was  made  for  a  radical  cure,  by  the  hypodermic  injection,  of  the  disorder 
under  which  this  patient  laboured.  But  what  was  of  interest  in  the  case, 
and  what  was  claimed  for  this  mode  of  treatment,  was,  First.  That  after 
other  measures  had  signally  failed,  the  subcutaneous  injection  afforded 
prompt,  and,  for  a  time,  complete  relief  from  pain.  Secondly.  That  by  the 
regular  repetition  of  the  injection  the  patient  was  made  comfortable, 
refreshing  sleep  obtained,  and  in  this  way  life  was  protracted  until  the 
weather  had  become  such  as  to  permit  him  to  use  those  hygienic  measures 
which  resulted  in  the  restoration  of  his  health.  Thirdly.  That  although 
the  injection  was  used  so  frequently,  and  for  such  a  long  time,  no  un- 
pleasant sequelae  resulted.  There  was  no  disturbance  of  the  head,  and  no 
nausea  ;  no  abscesses  of  the  cellular  tissue  formed  ;  and  although  the  points 
of  insertion  were  so  numerous  that  it  was  sometimes  difficult  to  find  a  spot 
where  the  instrument  had  not  already  been  introduced,  yet  all  these  healed 
readily,  and  there  was  now  nothing  left  to  indicate  where  the  injections 
had  been  used. 

"Under  these  circumstances  Dr.  L.  did  not  hesitate  to  recommend  the 
hypodermic  injection  as  a  valuable  addition  to  our  modes  of  medication. 


1863.] 


91 


REVIEWS. 

Art.  XV. — Consumption:  its  Early  and  Remediable  Stages.  By  Ed- 
ward Smith,  M.  D.,  F.  R.  S.,  Assistant  Physician  to  the  Hospital  of 
Consumption  and  Diseases  of  the  Chest,  Brompton,  etc.  etc.  London  : 
Walton  &  Maberly,  1862.    12mo.  pp.  44T. 

Does  the  clinical  history  of  pulmonary  tuberculosis  include  an  appreci- 
able period  prior  to  the  deposit  of  tubercle  in  the  lungs  ?  Few,  if  any,  at 
the  present  time,  regard  this  disease  as  primarily  local.  The  deposit  of 
tubercle  is  a  result  of  an  antecedent  morbid  condition  of  some  kind,  exist- 
ing somewhere  in  the  organism.  This  antecedent  morbid  condition  is,  in 
fact,  the  disease,  of  which  the  pulmonary  tuberculosis  is  the  local  expres- 
sion'; we  call  it  a  cachexia  or  a  clyscrasia,  and  our  present  pathological 
notions  lead  us  to  suppose  that  it  involves  some  special  blood-change.  Not 
stopping  to  consider  the  soundness  of  this  general  doctrine,  but  assuming 
it  to  be  most  consistent  with  our  existing  knowledge,  it  follows  that  there 
is  probably  a  period,  prior  to  the  deposit  of  tubercle,  when  the  disease  in 
reality  exists.  The  disease  exists  when  the  cachexia  has  been  produced ; 
the  cachexia  precedes  the  tubercular  deposit;  hence,  regarding  these  as 
consecutive  events,  it  is  reasonable  to  suppose  that  not  only  during  the 
production  of  the  cachexia,  but  after  it  has  been  produced,  more  or  less 
time  may  elapse  before  the  occurrence  of  the  local  expression  of  the  disease. 
Now,  the  question  is,  does  this  period  form  an  appreciable  part  of  the 
clinical  history  of  the  disease ;  in  other  words,  is  this  period  accompanied 
by  diagnostic  symptoms  ?  The  author  of  the  book,  the  title-page  of  which 
is  placed  at  the  head  of  this  article,  takes  the  ground  that  there  is  a  period, 
prior  to  the  deposit  of  tubercle,  which  is  to  be  considered  as  a  stage  of  the 
disease ;  he  calls  it  the  pre-tubercular  stage,  and  he  considers  this  stage  as 
rendered  appreciable  by  certain  general  and  local  symptomatic  events. 

The  importance  of  the  question  which  we  have  propounded  is  sufficiently 
apparent.  If  the  tuberculous  cachexia  exist,  for  a  greater  or  less  period, 
prior  to  the  tuberculous  exudation,  and  we  are  able  to  determine  the  exist- 
ence of  the  former  before  the  occurrence  of  the  latter,  we  may  hope  that 
the  diagnosis  during  this  period  may  be  made  of  immense  practical  value. 
It  is  reasonable  to  suppose  that  at  this  period,  more  than  at  any  other, 
the  disease  is  amenable  to  proper  management.  We  cannot  doubt  that 
the  tuberculous  cachexia  may  be  removed,  and  it  were  gratuitous  to  discuss 
the  advantage  of  removing  it  before  the  lungs  are  damaged  by  the  deposit 
of  tubercle.  The  only  questions  for  discussion  are,  How  are  we  to  ascer- 
tain the  existence  of  this  pre-tubercular  stage  ?  and,  What  measures  are  to 
be  pursued  to  effect  the  removal  of  the  cachexia  ?  Dr.  Smith  calls  this  a 
remediable  stage,  and  the  leading  object  of  his  work  is  the  consideration  of 
its  diagnostic  criteria,  together  with  the  management  of  the  tuberculous 
disease.  In  view  of  the  very  great  importance  of  the  subject,  we  propose 
to  review,  in  the  first  place,  that  portion  of  the  work  which  treats  of  a 
pre-tubercular  stage;  and,  in  the  second  place,  the  therapeutical  views 
which  the  author  inculcates. 


02 


Reviews. 


[Jan. 


In  seeking  for  the  symptomatic  phenomena  which  belong  to  a  pre- 
tubercular  stage,  the  attention  is  to  be  directed  to  symptoms  referable  to 
the  pulmonary  organs,  as  well  as  other  parts  of  the  body  and  the  system 
at  large,  and  to  the  physical  signs.  The  author  adopts  this  division  of 
signs  and  symptoms,  and  considers  the  latter  first.  His  method  of  inves- 
tigation consists  in  inquiring  of  a  large  number  of  phthisical  patients 
respecting  the  different  functions  of  the  body  prior  to  the  obvious  manifes- 
tations of  pulmonary  disease.  As  a  method  of  obtaining  evidence  of  a 
pre-tubercular  stage,  this  method  is  open  to  criticism.  What  proof  have 
we  that  the  various  functional  disturbances  thus  ascertained  are  either 
effects  or  concomitants  of  a  tuberculous  cachexia  prior  to  the  deposit  of 
tubercle  ?  They  may  have  preceded  the  cachexia,  and  perhaps  contributed 
to  its  production,  being  causes  rather  than  consequences  of  it ;  or,  on  the 
other  hand,  they  may  not  have  preceded,  but  followed,  the  tuberculous 
deposit,  the  latter  not  having  been  at  once  manifested  by  obvious  pul- 
monary symptoms.  To  determine  with  any  degree  of  positiveness  the 
symptoms  of  a  pre-tubercular  stage,  we  must  have  adequate  proof  of  the 
non-existence  of  a  deposit  of  tubercle  after  a  certain  epoch,  and  the  date  of 
the  occurrence  of  a  deposit  must  be  fixed.  These  points  can  only  be 
settled  by  careful  physical  explorations.  Herein  lies  the  difficulty  of  ac- 
cepting the  results  of  the  author's  inquiries  of  phthisical  patients  as  evi- 
dence of  a  pre-tubercular  stage.  The  symptoms  which  he  ascertains  may 
have  preceded  the  cachexia,  or  they  may  have  followed  the  production  of 
the  cachexia  and  preceded  the  deposit  of  tubercle ;  or  they  may  have  fol- 
lowed the  deposit  of  tubercle.  Their  precise  relations  to  tubercle  are  not 
determined,  but,  whatever  these  may  be,  as  occurring  antecedently  to  the 
obvious  manifestations  of  pulmonary  disease,  they  are  interesting  and  im- 
portant.   We  proceed  to  give  succinctly  the  results  of  his  inquiries. 

The  appetite  was  seldom  natural,  but  was  somewhat  lessened  in  respect 
of  food  in  general  and  of  some  foods  in  particular,  and  was  commonly 
wayward  and  uncertain.  It  is  worthy  of  being  specially  noted  that  fatty 
articles  of  food  were  less  commonly  liked  than  by  persons  who  become 
affected  with  other  diseases.  There  was  commonly  some  derangement  of 
the  function  of  digestion,  but  frequently  the  derangement  was  small.  The 
amount  of  food  taken  was  commonly  somewhat  lessened.  The  assimilation 
of  food  was  commonly  defective,  and  the  weight  and  bulk  of  the  body 
were  almost  universally  lessened. 

The  elimination  of  fluid  by  the  skin  was  increased.  There  was  a  gene- 
ral tendency  to  defect  of  temperature  of  the  body.  The  muscular  power 
was  commonly  lessened.  The  circulation  was  commonly  enfeebled  and 
somewhat  quickened.  The  menstruation  was  frequently  disturbed,  and 
there  was  much  liability  to  leucorrhoea.  Muscular  pains  about  the  chest 
were  very  common.  There  was  commonly  a  state  of  hyperesthesia  of  the 
throat.  There  was  only  a  small  or  moderate  amount  of  coughing,  and  a 
small  amount  of  expectoration.  In  a  majority  of  cases  there  was  some 
degree  of  haemoptysis.  Much  of  the  coughing  and  expectoration,  and 
occasionally  the  hemorrhage,  the  author  refers  to  the  pharynx. 

The  foregoing  conclusions,  which  the  author  draws  from  his  interroga- 
tories, are  expressed  in  his  own  language.  We  have  omitted  details,  some 
of  which  must  have  cost  the  author  considerable  labour,  and  also  consider- 
ations explanatory  of  the  supposed  relations  of  the  disordered  functions  to 
the  tuberculous  cachexia.  We  repeat,  these  results  are«not  without  interest 
and  importance,  but  as  furnishing  diagnostic  symptoms  of  a  pre-tubercular 


1863.]  Smith,  Consumption.  93 

stage,  they  can  hardly  be  considered  as  having  much  significance  or  value. 
Would  the  physician  be  warranted  in  predicating  the  existence  of  a  tuber- 
culous cachexia  on  the  functional  disorders  just  quoted  ?  We  think  the 
reader  will  concur  in  the  opinion  that  this  question  cannot  be  answered  in 
tn*e  affirmative.  We  pass  to  the  physical  signs  referable  to  the  pulmonary 
organs. 

The  first  sign  mentioned  is  lessened  movement  of  the  chest.  The  dimin- 
ished expansion,  he  affirms,  exists  in  every  case.  It  is  general ;  that  is,  it 
is  not  confined  to  one  side  or  to  the  summit,  but  extends  over  all  the  move- 
ments of  respiration.  The  amount  of  inspired  air  is  lessened,  as  shown  by 
the  spirometer,  which  the  author  regards  as  less  fallacious  than  the  inspec- 
tion or  measurement  of  the  chest.  The  next  sign  is  involved  in  that  just 
noticed;  viz.,  feebleness  of  the  respiratory  murmur.  The  author  believes 
that  this  change  invariably  precedes  the  deposit  of  tubercle.  He  thinks 
that  a  diagnostic  character  of  the  weakened  murmur  which  precedes  tuber- 
cle, as  compared  with  the  weakness  caused  by  general  debility,  consists  in 
the  fact  that,  in  the  latter  case,  the  normal  intensity  of  the  murmur  is 
brought  out  by  forced  breathing,  while  it  is  otherwise  in  the  former  case. 

The  author  does  not  state  how  often  he  has  found  these  signs  present  at 
a  time  when,  as  he  believed,  tubercular  deposit  had  not  taken  place,  in  per- 
sons who  subsequently  became  tuberculous.  He  does  not  state  that  he  has 
even  observed  a  single  instance  of  this  kind.  We  think  he  was  bound  to 
present  the  data  on  which  his  statements  are  based.  Clinical  observation, 
of  course,  can  alone  furnish  the  proper  data  for  conclusions;  &  priori  rea- 
soning is  inadequate.  Nor  is  it  sufficient  to  say,  which  the  author  does 
not,  that  these  signs  were  found  in  persons  who,  it  is  believed,  would  have 
had  a  deposit  of  tubercle  if  proper  measures  had  not  been  taken  to  prevent 
this  result.  In  order  to  consider  these  signs  as  denoting  a  condition  of  the 
lungs  in  which  a  deposit  of  tubercle  has  not  yet  taken  place,  but  will  take 
place  unless  prevented,  they  must  be  shown  to  have  existed  in  cases  of  con- 
firmed tuberculous  disease  at  a  time  when  there  was  satisfactory  proof  that 
the  deposit  had  not  taken  place.  This  evidence  of  their  diaguostic  signifi- 
cance the  author  may  have  obtained  sufficiently  for  his  own  satisfaction, 
but  he  does  not  present  it  to  the  reader. 

We  must  say  that,  were  these  signs  proven  to  represent  physical  condi- 
tions which  precede  the  deposit  of  tubercle,  we  much  doubt  their  availability 
in  diagnosis  to  any  great  extent.  Diminished  respiratory  movements,  less- 
ened vital  capacity,  and  enfeebled  respiratory  murmur,  express  deviations, 
not  from  any  fixed  normal  standard  applicable  to  all  healthy  persons,  but 
to  a  standard  of  health  proper  to  each  individual.  There  are  wide  varia- 
tions in  these  respects  among  different  persons  in  health.  All  who  have 
given  much  attention  to  examinations  of  healthy  chests  must  be  aware  of 
this  fact.  To  be  able  to  judge,  in  any  case,  with  respect  to  these  signs,  we 
must  know  the  healthy  standard  in  the  person  examined.  This  knowledge 
we  seldom  have,  because  persons  in  health  do  not  present  themselves  for 
examination.  This  difficulty  would  not  be  nearly  so  great  if  the  signs 
which  have  been  mentioned  were  limited  to  a  portion  of  the  chest;  we* 
should  then-  have  the  advantage  of  a  comparison  of  the  two  sides.  We 
confess  we  are  unable  to  understand  how  the  author  can  come  to  a  conclu- 
sion respecting  a  general  diminution  of  the  breathing  movements,  of  the 
amount  of  inspired  air,  and  of  the  respiratory  murmur,  in  individual  cases, 
unless  it  have  so  hajTpened  that  he  is  familiar  with  the  patient's  condition 
in  these  respects  when  in  perfect  health. 


94 


Reviews. 


[Jan. 


Dulness  on  percussion  is  another  sign  of  the  pretubercular  stage  to 
which  the  author  attaches  much  importance.  He  thinks  that,  before  the 
deposit  of  tubercle,  there  is  an  appreciable  degree  of  dulness  on  the  clavi- 
cles and  over  the  chest  in  general.  He  attributes  it  to  the  absence  of  the 
full  amount  of  air  in  the  lung  tissue.  This  dulness,  although  general, 'is 
apt  to  preponderate  on  one  side.  The  remarks  with  reference  to  the  dimin- 
ished breathing  movements  and  murmur  are  equally  applicable  here,  in  so 
far  as  dulness  over  the  whole  chest  is  concerned.  If  the  practitioner  be 
not  familiar  with  the  normal  resonance  of  his  patient,  how  is  he  to  decide 
that  it  is  abnormally  diminished,  in  view  of  the  wide  differences,  in  this  re- 
spect, in  different  persons  in  health?  If  relative  dulness  exist  on  one  side, 
as  compared  with  the  other  side,  the  first  question  is,  may  it  not  be  owing 
to  a  normal  disparity  ?  A  disparity  exists  to  which  the  author  does  not 
refer.  The  right  side,  at  the  summit,  is  slightly  dull  as  compared  with  the 
left  side.  This  disparity  is  more  or  less  marked  in  most  healthy  persons 
when  percussion  is  practised  with  the  care  and  delicate  comparison  of  sounds 
of  which  the  author  speaks.  The  next  question  is,  if  the  dulness  be  not 
due  to  the  normal  disparity,  may  it  be  fairly  attributable  to  diminished  ex- 
pansion of  lung  prior  to  the  deposit  of  tubercle,  or  does  it  not  denote  the 
existence  of  the  deposit?  We  must  confess  that  an  abnormal  dulness  at 
the  summit  of  the  chest  on  one  side,  existing  in  a  case  in  which  subsequently 
unmistakable  proof  of  tubercle  was  developed,  would,  for  us,  be  evidence 
that  tubercle  already  existed;  in  other  words,  the  author  adduces  no  facts 
which  go  to  show  that  dulness  precedes  the  deposit  of  tubercle. 

We  have  cited  the  only  signs  which  the  author  adduces  as  representing 
the  condition  of  the  pulmonary  organs  in  the  pretubercular  stage.  As- 
suming that,  probably,  such  a  stage  in  reality  exists,  and  concurring  fully 
with  the  author  in  the  importance  of  its  practical  recognition,  we  are  forced 
to  conclude  that  he  fails  to  indicate  symptoms  and  signs  sufficiently  dis- 
tinctive to  be  available  in  diagnosis,  or  facts  adequate  to  establish  its  ex- 
istence. The  candor  of  criticism  compels  us  to  say  this  ;  but,  in  saying  it, 
we  would  not  disparage  the  value  of  the  work  as  regards  the  interesting  and 
useful  considerations  which  it  presents  relating  to  the  causation,  pathology, 
and  symptomatology  of  tubercle.  While  it  does  not  claim  to  be  a  com- 
prehensive treatise  on  the  subject,  we  are  sure  that  the  medical  reader  will 
peruse  it  with  gratification  and  profit. 

The  author  considers  not  only  the  pretubercular  stage  of  the  disease,  but 
its  early  and  remediable  stages.  The  experience  of  all  practitioners  will 
confirm  the  statement  that,  in  the  great  majority  of  cases,  tuberculous 
patients  do  not  make  application  for  medical  aid  until  after  the  deposit  of 
a  greater  or  less  amount  of  tubercle.  It  is  an  early  and  a  remediable  stage 
when  the  deposit  is  recent  and  the  quantity  small.  Other  things  being 
equal,  the  disease  is  remediable  in  proportion  to  its  short  duration  and  the 
little  damage  to  the  lungs  which  the  deposit  has  occasioned.  We  cannot 
but  suspect  that  Dr.  Smith  has  considered  cases  as  in  a  pretubercular  stage 
when  a  tubercular  deposit  already  existed;  but,  waiving  the  discussion  of 
•  this  point,  how  vastly  important  is  it  to  recognize  the  existence  of  a  small 
deposit  of  tubercle !  There  is  scarcely  a  problem  in  practical  medicine  of 
greater  importance  than  the  diagnosis  of  pulmonary  tuberculosis  shortly 
after  the  occurrence  of  the  deposit.  We  should  have  been  glad  if  the  author 
had  considered  more  fully  than  he  has  done,  the  diagnostic  symptoms  and 
signs  of  this  stage  of  the  disease.  We  believe  that- the  diagnosis  may  be 
made  in  most  cases  at  a  very  early  period  after  the  deposit  has  taken  place. 


1863.] 


Smith,  Consumption. 


95 


We  make  this  statement  after  a  long  and  pretty  extensive  experience.  But 
the  diagnosis  involves  a  degree  of  attention  to  physical  signs  which  is  be- 
stowed by  few  practitioners.  We  hope  not  to  be  misapprehended  in  this 
remark.  We  are  far  from  wishing  to  arrogate  any  special  skill;  we  mean 
only  that  auscultation  and  percussion  are  not  sufficiently  studied  by  practi- 
tioners in  general.  A  prevalent  belief  that  practical  skill  is  more  difficult 
of  acquirement  than  it  really  is,  doubtless  contributes  not  a  little  to  a  neg- 
lect which  is  much  to  be  regretted. 

We  do  not  propose  to  consider  the  points  involved  in  the  early  diagnosis 
of  tubercle.  To  do  this  would  require  too  much  space,  and,  moreover, 
would,  in  this  connection,  be  out  of  place.  We  will  only  say  that  the 
diagnosis  requires  a  practical  knowledge  of  the  distinctive  characters  of 
physical  signs,  based  on  an  analysis  of  the  abnormal  sounds,  and  a  com- 
parison with  the  normal  sounds  as  regards  differences  relating  to  pitch, 
quality,  intensity,  and  rhythm ;  it  requires  a  practical  acquaintance  with 
the  normal  disparity  between  the  two  sides  of  the  chest  in  the  sounds  ob- 
tained by  auscultation  and  percussion,  and  it  requires  a  fair  amount  of  the 
judgment  and  tact  which  are  only  to  be  acquired  by  practice.  The  import- 
ance of  the  object  should  secure  for  the  means  of  diagnosis  more  attention 
than  they  generally  receive. 

One-half  of  Dr.  Smith's  work  is  devoted  to  the  treatment  of  tuberculosis. 
We  find  in  this  portion  of  the  work  no  occasion  to  join  issue  with  the 
author,  but,  on  the  contrary,  much  which  we  would  commend  to  the 
reader's  attention.  Dr.  Smith  attaches  far  greater  importance  to  hygienic 
measures  than  to  drugs,  in  the  treatment  of  the  disease.  This  is  a  point 
to  be  impressed  on  the  minds  not  only  of  practitioners,  but  of  tuberculous 
patients.  The  latter  must  understand  fully  that  the  arrest  of  the  disease 
is  not  to  be  effected  by  any  special  medication.  Understanding  this,  they 
will  place  their  dependence  on  those  measures  of  diet  and  regimen  which 
will  not  be  likely  to  be  properly  carried  out  save  with  the  conviction  that 
the  reliance  is  chiefly  on  these  measures.  For  the  successful  management 
of  tuberculosis,  the  faithful  co-operation  of  the  patient  is  essential,  and 
failure  of  success  not  infrequently  may  be  attributed  to  want  of  sufficient 
energy  and  perseverance  on  the  part  of  the  patient. 

Dr.  Smith  regards  the  inunction  of  oils  or  fats  as  productive  of  a  certain 
amount  of  benefit  by  restraining  excessive  elimination  of  fluids  from  the 
skin,  and  protecting  the  surface  against  atmospherical  impressions.  He 
considers  its  beneficial  agency  as  altogether  mechanical,  attributing  nothing 
to  absorption.  He  prefers  the  ordinary  spermaceti  ointment  for  the  in- 
unction. It  should  be  continued  for  several  successive  days,  and  then  in- 
termitted for  a  short  time.  Sponging  the  surface  with  cold  water,  followed 
by  brisk  friction,  he  recommends  in  the  intervals  when  inunction  is  omitted, 
and  habitually  when  inunction  is  not  resorted  to.  Of  the  latter  measure 
we  can  speak  favourably  from  experience.  There  are  few  cases  in  which, 
with  proper  precautions,  it  may  not  be  resorted  to  with  advantage. 

As  regards  clothing,  his  views  appear  to  us  highly  judicious.  The  sur- 
face is  to  be  protected  against  changes  of  temperature  by  garments  worn 
next  the  skin,  composed  of  materials  which  are  good  non-conductors  of 
heat,  and,  with  this  protection,  the  body  is  to  be  kept  cool  instead  of  being 
over-heated.  A  superabundance  of  clothing  is  not  less  hurtful  than  a  defi- 
ciency ;  perhaps  even  more  so,  on  account  of  the  loss  of  fluids  by  perspira- 
tion, and  the  increased  susceptibility  of  the  skin  to  atmospherical  influences. 
An  excess  of  clothing  interferes  with  active  exercise,  owing  to  the  encum- 


96 


Reviews. 


[Jan. 


brance,  and  the  inconvenience  from  heat  and  sweating.  Dr.  Smith  enjoins 
that  flannel  should  be  worn  next  the  skin.  Raw  silk  is  perhaps  an  equally 
good  non-conductor  of  heat,  and  may  be  substituted  when  preferred.  But, 
in  a  cold  climate,  we  think  the  chamois-leather  jacket  worn  over  light 
woollen  or  silk,  is  to  be  strongly  recommended.  It  is  sufficiently  porous, 
aud  affords  such  substantial  protection  that  cumbrous  outer  garments  may 
be  dispensed  with.  With  the  body  properly  protected,  out-door  life  is  to 
be  advised,  and  exposure  in  almost  all  kinds  of  weather  is  not  only  admis- 
sible, but  advisable.  There  is  no  hygienic  measure  in  the  treatment  of 
tuberculosis  of  greater  importance  than  this.  In  how  many  cases  has  a 
favourable  progress  in  this  disease  been  retarded,  or  prevented,  by  needless 
apprehensions  of  exposure  and  of  over-exertion  !  We  may  here  remark 
that  tuberculous  patients,  as  a  rule,  are  not  more  prone  to  attacks  of  bron- 
chitis or  colds,  than  healthy  persons ;  and,  when  such  attacks  occur,  they 
do  not  appear  to  exert,  any  marked  influence  on  the  tuberculous  disease. 

The  author  is  fully  impressed  with  the  importance  of  abundant  aliment- 
ation, and  of  supplying  a  proper  variety  of  alimentary  principles.  Fatty 
articles  should,  if  possible,  form  a  fair  proportion  of  the  diet.  The  author 
remarks  that  some  persons  who  have  a  disinclination  for  most  kinds  of  fat, 
are  able  to  take  certain  kinds  without  repugnance.  He  reckons  alcoholics 
among  the. articles  of  food,  and  considers  them  as  important,  but  not  ex- 
erting any  special  anti-tuberculous  influence.  Many  practitioners  on  this 
side  of  the  Atlantic  consider  alcoholics  as  useful,  remedially,  in  tuberculosis, 
and  in  this  view  we  have  participated.  We  are  satisfied,  however,  that  all 
are  not  benefited  alike  by  them,  and  that,  in  some  cases,  they  are  not  useful. 
They  should  never  be  given  to  the  extent  of  affecting  the  brain,  accelerating 
the  circulation,  producing  perspiration,  or  inducing  an  indisposition  to 
muscular  exertion.  The  patient  should  be  sensible  of  an  agreeable  and 
beneficial  effect  of  their  use ;  if  not,  they  will  not  be  likely  to  be  useful. 
We  would  add  to  the  articles  which  are  especially  useful,  sugar.  This 
should  enter  into  the  diet  as  largely  as  the  taste  of  the  patient  will  allow, 
provided  it  do  not  occasion  disturbance  of  digestion.  We  are  tempted  to 
quote  the  author's  directions  as  regards  food  in  the  early  stage  of  phthisis. 
It  will  be  seen  how  vigorously  he  enforces  alimentation.  Perhaps  he  pushes 
this  part  of  the  treatment  to  an  extreme ;  but  it  is  better  to  err  in  that 
direction  than  on  the  side  of  deficiency.  Upon  alimentation  and  out-door 
life,  improvement  and  recovery  depend  vastly  more  than  upon  any  of  the 
other  measures  of  treatment.    We  quote  from  the  work  as  follows: — 

"The  patient  should  take  from  two  to  three  pints  of  milk  daily,  prepared  (and 
we  would  add  thickened)  with  chocolate,  arrowroot,  flour,  gluten,  semola,  oatmeal, 
or  bread,  or  made  with  eggs,  etc.  into  puddings.  In  cases  where  new  milk  does 
not  agree,  skimmed  milk  may  be  in  part  supplied,  and  then,  if  fats  be  tolerated, 
half  an  ounce  of  suet,  cut  finely,  should  be  well  boiled  in  each  pint  of  milk  and 
taken  quite  warm.  The  milk  should  be  eaten  in  somewhat  small  quantities,  say 
half  a  pint  at  a  time ;  one  quantity  is  to  be  taken  immediately  on  the  patient 
awaking  in  the  morning,  others  at  breakfast  and  supper,  the  milk  pudding  for 
dinner,  and  chocolate  or  coffee  may  be  added  to  the  milk  which  is  taken  at 
breakfast  and  tea.  Food  should  further  be  taken  at  intervals  of  from  two  to 
three  hours,  and  the  dinner  should  be  supplied  soon  after  mid-day.  Half  a  pint 
of  good  soup,  with  bread,  may  be  taken  between  breakfast  and  dinner,  and,  if 
fats  are  not  disliked,  it  would  be  better  to  prepare  the  soup  from  ox  heads  or 
shins,  so  as  to  supply  both  oil  and  jelly  in  addition  to  the  juices  of  the  meat, 
and  the  whole  should  be  well  thickened  with  groats  or  corn  flour.  Eggs,  bacon 
or  meat  should  be  taken  at  breakfast,  and  abundance  of  fresh  meat  at  dinner, 
with  soup,  pudding,  and  a  moderate  quantity  of  fresh  vegetables,  French  beans, 


1863.J 


Salter,  Asthma. 


97 


and  bread.  The  meat  should  be  of  the  richest  quality,  and  have  at  least  one- 
third  of  its  weight  of  fat.  If  the  patient  like  salad  oil,  it  may  be  eaten  as  freely 
as  possible.  A  small  quantity  of  cheese  should  be  added  to  the  dinner.  An 
egg  should  be  taken  at  the  tea  meal,  and  also  at  supper  when  milk  is  not  taken. 
There  should  also  be  a  cup  of  milk  and  bread  and  butter  placed  at  the  bedside 
of  the  patient,  and  eaten,  if  possible,  during  the  night.  Beer  or  wine  may  be 
taken  at  dinner  and  once  or  twice  at  other  periods  of  the  day,  if  it  be  found  to 
agree  with  the  system,  and  the  dose  be  so  moderated  that  it  may  not  in  the  least 
affect  the  head,  or  cause  heaviness  in,  and  indisposition  to  move  the  limbs. 
Usually  wine  should  be  taken  with  hot  water ;  but  when  the  progress  of  the 
case  is  satisfactory,  alcohols  are  not  necessary.  All  food  should  be  taken  hot, 
and  prepared  so  as  to  please  the  taste  of  the  patient."  (p.  329.) 

The  reader  will  perhaps  be  led  to  say  that  the  author  gives  the  patient 
but  little  time  to  do  aught  else  than  to  eat.  Exclusive  of  out-door  exer- 
cise, he  cannot  do  anything  more  conducive  to  his  welfare.  There  is,  of 
course,  a  limit  to  dietetic  measures;  the  digestive  powers  must  not  be  over- 
tasked, but  their  fullest  capabilities  are  to  be  made  available,  and  this  can 
be  done  by  systematic,  persevering  efforts  to  a  far  greater  extent  than  is 
generally  supposed. 

Dr.  Smith  recommends  the  practice  of  promoting  expansion  of  the  lungs 
by  voluntary  efforts  of  deep  inspiration.  Whatever  advantage  accrues  from 
this,  may  be  obtained,  as  it  seems  to  us,  by  muscular  exercise  in  the  open 
air. 

The  remedies  which  he  deems  useful  with  reference  to  the  arrest  of  tuber- 
culous disease;  are  chiefly  those  which  promote  appetite  and  digestion.  For 
these  objects  he  advises  the  tinct.  ferri  sesquichloridi,  or  the  citrate  of  iron 
and  quinine,  with  some  of  the  bitter  infusions.  Cod-liver  oil  is  advisable 
when  tolerated.  For  the  cough  he  considers  the  best  remedy  to  be  1-1 6th 
or  1-1 2th  of  a  grain  of  morphia  in  mucilage  or  syrup. 

The  last  seventy  pages  of  the  work  are  devoted  to  the  climatic  advan- 
tages of  certain  situations,  viz.,  Scarborough,  the  Isle  of  Man,  Scotland, 
Switzerland,  various  parts  of  England,  the  Nile,  Pau,  Madeira,  and  Rome. 
He  presents  details  respecting  humidity,  mean  temperature,  etc.,  of  several 
of  these  situations. 

In  taking  leave  of  the  work,  we  would  express  the  hope  that  the  author 
will  furnish  occasions  for  a  renewal  of  our  intercourse  as  a  reader,  if  not 
as  a  reviewer.  A.  F. 


Art.  XYI. — On  Asthma;  its  Pathology  and  Treatment.    By  Henry 
Hyde  Salter,  M.D.,  F.R.  S.    London,  1860.    8vo.  pp.  372. 

The  only  sure  foundation  for  the  rational  treatment  of  a  disease,  is  an 
accurate  knowledge  of  the  pathological  elements  which  it  involves,  and  its 
separation  as  a  morbid  entity  from  all  analogous  affections,  as  well  as  from 
the  phenomena  which  accidentally  become  attached  to  it.  When  this  object 
has  been  attained,  and  then  only,  does  it  become  possible  to  discover  its 
pathogenesis,  or  accurately  to  determine  the  value  and  the  mode  of  opera- 
tion of  the  several  remedies  which  are  employed  for  its  cure.  So  in  chem- 
istry the  isolation  of  a  substance  from  its  associated  substances  forms  the 
preliminary  step  to  an  investigation  of  its  nature  and  habitudes.  Without 
such  an  isolation  of  a  disease,  all  discussions  respecting  its  nature  lead  to 
No.  LXXXIX.— Jan.  1863.  7 


98 


Reviews. 


[Jan. 


results  as  imperfect  or  erroneous  as  the  estimate  of  a  chemical  element  does 
which  has  never  been  examined  except  in  combination.  It  is  often  claimed 
that  the  great  glory  of  natural  science  in  the  present  age  is  the  application 
of  a  rigorous  method  of  analysis  to  its  study ;  but  this  is  quite  as  true  of 
human  physiology  and  pathology  as  it  is  of  any  among  the  sister  sciences. 
Indeed,  if  we  examine  the  progress  of  medicine  during  the  last  half  century, 
we  shall  be  convinced  that  a  very  large  proportion  of  it  has  been  achieved 
by  the  separation  of  morbid  states  which  were  previously  confounded,  or 
which  were  only  imperfectly  distinguished  from  one  another,  and  by  the 
subsequent  experimental  application  to  each  of  them  of  different  methods  of 
cure. 

Such  a  work  has  been  performed  for  "Asthma"  in  the  volume  which  we 
propose  to  examine,  its  object  being  to  prove  "that  asthma  is  essentially, 
and,  with  perhaps  the  exception  of  a  single  class  of  cases  (the  humoral), 
exclusively,  a  nervous  disease :  that  the  nervous  system  is  the  seat  of  the 
essential  pathological  condition." 

The  author  devotes  some  space  to  refuting  certain  theories,  and  particu- 
larly Dr.  Bree's  hypothesis  that  the  phenomena  of  the  asthmatic  paroxysm 
are  due  to  an  extraordinary  effort  to  get  rid  of  some  peccant  and  irritating 
matter  existing  in  the  air  tubes.  But  this,  we  think,  is  labour  lost ;  for 
the  hypothesis  is  purely  and  simply  gratuitous,  nothing  whatever  having 
been  brought  forward  by  its  author  which  is  capable  of  affording  it  the 
slightest  foundation.  If  he  had  possessed  the  light  afforded  by  more  recent 
observation,  he  would  probably  have  modified  his  views  so  as  to  embrace 
the  numerous  instances  cited  elsewhere  in  the  present  work,  which  appear 
to  prove  that  certain  substances  after  digestion  and  absorption  act  as  specific 
irritants  upon  the  lungs.  But  this  theory  involves  the  element  of  spasm, 
which  Dr.  Bree  did  not  accept:  Equally  illogical,  and  founded  upon  unreal 
pathological  conditions,  are  the  notions  that  asthma  depends  upon  bronchial 
mucus,  or  upon  thickening  of  the  lining  membrane  of  the  bronchia.  Evi- 
dently, these  permanent  conditions  cannot  be  invoked  to  account  for  pheno- 
mena the  characteristic  peculiarity  of  which  is  their  sudden  occurrence  in 
the  midst  of  apparently  good  health,  and  often  without  the  intervention  of 
any  palpable  exciting  cause.  It  deserves  to  be  remarked,  in  the  words  of 
Sir  John  Floyer,  that  "  the  lungs  do  not  appear  to  be  much  oppressed  with 
phlegm  before  the  fit ;  and  at  the  end  of  the  fit  the  straituess  goes  off  before 
any  considerable  quantity  is  spit  up."  Dr.  Mason  Good  quotes  this  pas- 
sage as  describing  what  he  himself  had  witnessed,  and  in  opposition  to  the 
theory  of  Dr.  Bree,  and  elsewhere  refers  to  the  fact  it  describes  as  proving 
evidently  "  that  the  inner  membrane  of  the  bronchial  vessels  is  in  a  state 
of  peculiar  dryness."  (Study  of  Medicine,  i.  557.)  Certain  speculatists 
conceive  that  there  is  a  specific  something  circulating  in  the  blood  whose 
property  it  is  to  excite  asthmatic  attacks.  We  find,  it  is  true,  that  par- 
ticular articles  of  food,  almost  as  various  as  the  cases  of  the  disease  are 
numerous,  tend  habitually  in  the  same  person  to  develop  the  paroxysms ; 
but  these  facts  evidently  prove  the  peculiar  susceptibility  of  the  patient 
himself  rather  than  the  special  virulence  of  the  noxious  agent;  they  indi- 
cate, indeed,  a  nervous  rather  than  a  humoral  pathology  for  the  affection. 
The  late  Dr.  Todd,  like  Dr.  Bree,  argued  in  favour  of  a  special  materies 
morbi,  because,  according  to  him,  asthma  in  many  points  resembles  gout. 
Dr.  Salter  thinks  it  worth  while  to  state  this  theory  at  length  and  seriously 
to  refute  it.  The  reputation  of  its  author  may  have  seemed  to  require  this 
trouble ;  the  theory  itself  certainly  did  not. 


1863.] 


Salter,  Asthma. 


99 


During  the  prevalence  of  doctrines  which  emanated  from  the  school  of 
the  pathological  anatomists,  it  was  difficult  to  procure  belief  in  the  existence 
of  any  disease  which  did  not  impress  upon  the  organs  a  material  change. 
When  not  even  the  primary  lesions  of  the  inflammatory  process  could  be 
detected,  a  state  called  irritation  was  assumed  to  exist,  which  appears  to 
have  been  a  hypothetical  organic  nisus  towards  inflammation.  It  had  little 
in  common  with  that  sort  of  impression  upon  one  portion  of  the  nervous 
system  which  awakens  action  in  another,  and  perhaps  distant  part,  a  phe- 
nomenon which  belongs  to  the  province  of  nervous  pathology,  and  which, 
although  formerly  recognized  distinctly,  did  not  until  recently  become 
familiar  as  a  mode  of  morbid  as  well  as  of  normal  action.  It  is,  indeed, 
hardly  to  be  wondered  at,  that  the  brilliant  discoveries  made  of  the  con- 
nection between  symptoms  and  organic  lesions  should  for  a  period  have 
blinded  pathologists  to  the  nervous  elements  of  disease,  and  that  the  idea 
of  purely  nervous  affections  should  have  excited  a  feeling  not  unlike  deri- 
sion. We  may,  therefore,  pardon  so  accomplished  a  physician  as  Dr. 
George  Budd  when,  as  late  as  1840,  he  avowed  his  scepticism  in  regard  to 
the  existence  of  pure  nervous  asthma;  and  we  cannot  feel  great  surprise 
that  Laennec  himself  should  have  been  obliged  to  say  that  "  among  contem- 
porary physicians,  who  have  most  cultivated  morbid  anatomy,  many  alto- 
gether deny  the  possibility  of  spasmodic  dyspnoea,  and  most  of  the  others 
are  disposed  to  embrace  the  same  opinion."  In  1817,  Rostan  attributed 
all  cases  of  asthma  to  diseases  of  the  heart  or  of  the  great  vessels.  Brous- 
sais  held  the  same  doctrine ;  and  in  1844,  the  learned  commentator,  Dr. 
Adams,  wrote  :  "  It  seems  likely  that  the  paroxysm  is  occasioned  by  thick 
and  viscid  mucus  infarcted  in  the  lungs."  Even  M.  Beau,  the  dexterous 
physical  diagnostician,  appears  to  have  used  his  peculiar  skill  only  as  guide 
to  error  in  this  matter ;  for  he,  like  the  writer  just  named,  attributes  all 
the  phenomena  of  asthma  to  bronchitis.  Nor  did  he  so  in  ignorance  of  the 
doctrine  of  bronchial  spasm  ;  since  he  blames  those  who  maintain  it  for  an 
undue  deference  to  medical  tradition. 

There  is  another  theory  from  which  Dr.  Salter  dissents,  not  because  it 
ignores  the  nature  of  the  elements  involved  in  asthma,  but  because  it  im- 
poses a  wrong  interpretation  upon  the  phenomena  of  the  disease ;  it  is 
that  which  attributes  them  to  paralysis  of  the  bronchial  tubes.  To  this 
he  objects  as  involving  the  supposition  that  the  tubes  are  agents  of  respi- 
ration, a  supposition  to  which,  in  common  with  Dr.  Budd,  he  emphatically 
objects,  because  "respiration  is  under  the  influence  of  the  will,  while  the 
contraction  of  the  bronchial  tubes  is  essentially  involuntary."  According  to 
Dr.  Budd,  we  should,  therefore,  by  quickening  the  respiratory  acts,  speedily 
cause  the  proper  accordance  between  the  dilatation  of  the  chest  and  that  of 
the  bronchia  to  cease,  and  the  one  to  dilate  while,  the  others  were  contract- 
ing. This  would,  certainly,  be  the  case  if  the  rate  of  movement  of  the 
muscles  of  the  bronchia  were  uniformly  the  same  ;  but  for  such  a  supposi- 
tion there  is  no  ground  whatever.  The  muscles  of  the  heart,  of  the  intes- 
tines, &c,  contract  more  or  less  rapidly  according  to  the  more  or  less  fre- 
quent renewal  of  the  stimulus  which  excites  them,  and  no  idea  of  normal 
muscular  contraction  of  the  bronchia  can  be  conceived  which  does  not 
imply  its  perfect  reciprocity  with  those  general  thoracic  movements  which 
are  involved  in  the  respiratory  act.  To  say  that  respiration  "is  under  the 
influence  of  the  will,"  implies  the  movement  at  a  quicker  or  slower  rate  of 
all  the  muscles  concerned  in  that  act,  bronchial  as  well  as  thoracic ;  and 
we  are  not  authorized  to  assume  for  the  latter  and  deny  to  the  former  a 


100 


Reviews. 


[Jan. 


subjection  to  volition,  when  it  is  evident  that  both  must  move  simulta- 
neously, or  at  least  co-ordinately.  Besides,  it  is  scarcely  correct  to  oppose 
these  two  sets  of  muscles  as  voluntary  and  involuntary.  The  thoracic 
muscles  have  the  one  character  or  the  other,  accordiug  to  circumstances. 
However  we  may,  for  a  limited  period,  by  an  act  of  volition,  control  the 
rate  of  their  movements,  they  are  none  the  less  involuntary  muscles  during 
sleep  and  in  all  other  states  of  unconsciousness. 

But  because  the  movements  of  the  bronchial  muscles  must  be  synchro- 
nous with  those  of  the  chest,  whatever  their  rate  of  motion,  it  does  not 
follow  that, in  asthma  the  former  are  paralyzed.  Nor  do  we  perceive  the 
validity  of  the  admission  made  by  Dr.  Salter  that  this  view  would  lend  a 
ready  explanation  to  "  the  extreme  difficulty  and  prolongation  of  expira- 
tion." On  the  contrary,  it  would  seem  as  if  the  air  should  be  more  rapidly 
expelled  in  expiration  if  the  bronchia  opposed  no  obstacle  to  its  escape, 
such  as  would  exist  if  they  were  contracted,  provided  the  contractility  of 
the  lungs  remained  unimpaired.  Another  reason  which,  in  the  opinion  of 
Dr.  S.,  favours  the  paralysis  theory,  is  "the  permanent  state  of  distension 
at  which  the  chest  is  kept  during  the  asthmatic  paroxysm."  But  if  this 
state  does  not  exist,  as  an  essential  part  of  the  paroxysm  (which  we  shall 
endeavour  to  make  probable),  the  theory  is  no  longer  to  be  entertained. 

The  second  chapter  of  the  present  work  sets  forth  the  doctrine,  which  it 
is  one  of  the  author's  principal  objects  to  expound,  viz.,  that  asthma  is 
essentially  a  nervous  disease.  This  proposition  is  very  fully  and  very  ably 
demonstrated.  The  causes,  it  is  shown,  are  chiefly  such  as  operate  upon  the 
nervous  system,  among  which  mental  influences  hold  a  conspicuous  place, 
and  particularly  sudden  alarm  and  other  emotional  excitements.  These  are 
equally  remarkable  for  suspending  or  arresting  the  paroxysm  in  many  cases. 
The  most  efficient  remedies  are  from  among  those  which  act  upon  the 
nervous  system,  and  in  an  especial  manner  certain  narcotics  and  antispas- 
modics. The  periodical  recurrence  of  the  attacks,  and  particularly  their 
proneness  to  take  place  at  night  when  the  susceptibility  of  the  nervous 
system  is  peculiarly  alive ;  the  copious  excretion  of  limpid  urine,  the  neu- 
ralgia and  frontal  headache,  the  antecedent  drowsiness  and  languor,  or, 
on  the  other  hand,  the  unwonted  hilarity  and  animation  which  often  pre- 
cede the  paroxysms,  are  phenomena  of  the  same  class. 

The  second  proposition  of  Dr.  Salter  is — 

"That  the  phenomena  of  asthma — the  distressing  sensation,  and  the  demand 
for  extraordinary  respiratory  efforts — immediately  depend  upon  a  spastic  con- 
traction of  the  fibre-cells  of  organic  muscle,  which  minute  anatomy  has  demon- 
strated to  exist  in  the  bronchial  tubes." 

After  showing  that  these  phenomena  are  not  to  be  ascribed  to  heart  dis- 
ease, bronchitis,  or  emphysema,  the  author  calls  attention  to  the  fixed  and 
rigid  immobility  of  the  thoracic  walls,  and  the  absence  of  respiratory  mur- 
mur during  the  paroxysm,  even  while  the  external  muscles  are  labouring  by 
violent  action  to  move  the  chest.  In  other  words,  the  distress  of  the  patient 
is  evidently  owing  to  the  difficulty  which  the  air  experiences  in  reaching  the 
pulmonary  vesicles,  not  because  the  external  muscles  prevent  it — for  their 
action  is  intermittent,  and,  as  far  as  it  goes,  would  tend  to  dilate  the  chest 
and  introduce  the  air  for  lack  of  which  the  patient  is  suffering — but  because 
the  muscles  of  the  bronchia  themselves  diminish  the  calibre  of  these  canals, 
and,  by  preventing  the  ingress  of  air,  render  the  efforts  of  the  external  mus- 
cles abortive.    An  additional  evidence  of  this  fact  is  the  existence  of  sibilant 


1863.] 


Salter,  Asthma. 


101 


rhonchi  and  wheezing,  which  can  only  be  caused,  in  the  absence  of  mucus, 
by  the  irregular  contraction  of  the  tubes  themselves. 

"Thus  we  see,"  remarks  Dr.  S.,  "by  evidence  as  certain  as  sight,  that  in 
asthma  bronchial  spasm  must  and  does  exist,  and  that  no  other  conceivable 
supposition  will  explain  the  phenomena." 

The  author  then  alludes  to  the  anatomical  proofs  of  the  existence  of  cir- 
cular muscular  fibres  iii  the  bronchia,  even  to  their  minutest  divisions,  and 
points  ont  how  wide-spread  their  connection  is  with  various  organs  through 
the  vagus  nerve,  the  cervical  portion  of  the  sympathetic,  and  the  anterior 
and  posterior  pulmonary  plexus.  He  also  refers  to  the  experiments  of 
Tolkmann,  Williams,  and  others,  which  prove  that  the  bronchial  tubes  un- 
dergo contraction,  even  to  complete  occlusion,  from  the  application  of  vari- 
ous stimuli  both  to  the  tubes  themselves  and  to  the  trunks  of  the  pneumo- 
gastric  nerves. 

It  would,  we  think,  have  added  force  to  the  author's  reasoning  had  he 
informed  his  readers  that  the  doctrine  of  the  muscularity  of  the  bronchial 
tubes,  and  of  the  spasmodic  nature  of  asthma,  dates  far  back  of  the  dis- 
coveries and  experiments  to  which  he  alludes;  far  back,  also,  of  the  demon- 
stration of  the  circular  fibres  by  Keisseissen  (1821),  which  Dr.  Copland 
claims  as  his  own,  and  Cruveilhier  adjudges  to  himself;  and  even  from  an 
earlier  period  than  Cullen,  of  whom  Dr.  Budd  says,  "Since  the  time  of 
Cullen,  the  muscularity  of  these  fibres  has  been  adduced  to  explain  the 
symptoms  of  asthma."  Indeed,  after  Willis  wrote,  the  existence  of  bron- 
chial muscular  fibres  was  as  fully  admitted  as  that  of  the  muscles  of  the 
larynx  itself.  Nothing  can  be  more  explicit  than  the  description  which  this 
author  first  published  in  1673.  After  describing  the  straight  and  circular 
fibres  of  the  trachea,  he  says  : — 

"  The  coats  of  the  bronchia  have  muscular  fibres  of  both  kinds  ;  from  whence 
we  may  conclude  that  all  the  lesser  pipes  of  the  aspera  arteria  have  their  con- 
stant turns  of  systole  and  diastole,  viz :  all  the  pipes  are  contracted  when  we 
breathe  out,  and  relaxed  while  we  suck  in  air." 

This,  let  it  be  remarked,  is  also  the  very  furthest  and  latest  conclusion 
of  modern  physiology  on  the  subject. 

When  Willis  would  explain  the  phenomena  of  asthma,  he  says  : — 

"  The  animal  spirits  destined  to  the  function  of  breathing  ....  enter  inordi- 
nately into  the  fibres,  as  well  nervous  as  moving,  of  the  organs  of  breathing, 
and  make  them  for  that  one  cause  one  while  to  be  contracted,  another  while  to 
be  distended,  irregularly,  as  also  their  solemn  and  equal  turns  of  systole  and 
diastole  to  be  variously  disturbed  and  hindered."  (Of  the  Medicines  of  the 
Thorax,  1684.) 

Finally,  he  places  the  immediate  cause  of  the  paroxysm  either — 1,  in  the 
muscular  fibres  ;  or  2,  in  the  nervous  branches  ;  or  3,  in  the  brain.  If  for 
brain  we  write  nervous  centres,  we  shall  find  in  Willis  the  essence  of  the 
modern  pathology  of  asthma. 

Let  it  be  further  remarked  that  Willis  refers  to  the  belief  of  the  ancients, 
and  of  his  own  cotemporaries,  that  all  asthma  depends  on  mechanical  ob- 
structions of  the  air-passages,  while  he  himself  admits  asthma  from  me- 
chanical, and  asthma  from  spasmodic — or,  as  he  terms  them,  convulsive — 
causes.  He  even  goes  further,  and  points  out  how  an  asthma  which  was 
at  first  mechanical  only  may  become  convulsive  also,  just  as  we  see  spas- 
modic asthma  superadded  to  dyspnoea  produced  by  vesicular  emphysema. 

"  Hence,"  he  says,  "  it  may  be  concluded  that  every  asthma  is  a  mixed  affec- 


102 


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tion,  stirred  up  by  the  default  partly  of  the  lungs  ill-formed,  and  partly  by  a 
default  of  the  nerves  and  nervous  fibres  appertaining  to  the  breathing  part." 

If  we  apply  this  remark  to  the  confirmed  disease,  it  expresses  precisely 
what  the  most  recent  and  accurate  observation  has  taught. 

Bonetus,  the  cotemporary  of  Willis,  in  France,  and  scarcely  less  eminent, 
followed  in  the  same  doctrine.    There  are,  he  says, 

"Several  causes  of  dyspnoea;"  the  air  tubes  maybe  ''choked  up,  compressed, 
or  too  closely  contracted"  .  .  .  "The  branches  of  the  trachea  sometimes, 
their  fibres  being  spasmodically  affected,  are  too  much  drawn  up  and  quite 
closed,  and  prevent  the  ingress  of  air  necessary  for  respiration.  Hence,  although 
no  obstruction  exists  in  the  lung,  or  any  malformation,  or  any  consumptive  dia- 
thesis, yet  these  fibres  being  preternaturally  convulsed,  and  at  the  same  time 
contracted,  terrible  paroxysms  of  asthma  often  occur."  (Sepulchretum,  i.  385.) 

Again,  in  England,  a  few  years  later  (1698),  was  published  a  work  which 
is  still,  and  must  remain,  a  classic  in  the  literature  of  asthma.  In  this,  Sir 
John  Floyer  says  (p.  8): — 

"The  muscular  fibres  of  the  bronchia  and  vesiculse  of  the  lungs  are  contracted, 
and  that  produces  the  wheezing  noise  which  is  most  observable  in  expiration." 

And  again  (p.  43): — 

"This  contraction  of  the  vesiculce  is  very  probable,  because  the  bronchia  are 
contracted  and  the  vesiculce  have  the  same  muscular  fibres  to  help  respiration, 
by  which  they  may  be  drawn  up  so  as  not  to  admit  air." 

Muscular  fibres  of  the  vesiculae  !  Once  more  a  literal  anticipation  of  the 
farthest  reach  of  our  anatomical  research,  advanced  as  we  are  more  than 
a  century  and  a  half  beyond  Floyer  upon  the  road  of  scientific  discovery. 

Without  going  back  to  Yan  Helmont,  who,  even  before  Willis,  attributed 
the  phenomena  of  asthma  to  spasm  of  the  air-tubes,  we  must  not  omit 
noticing  the  testimony  of  that  giant  among  modern  physicians,  Frederic 
Hoffmann.    In  IT 07,  he  wrote  as  follows  :— 

"  While  the  diaphragm,  the  intercostals,  and  the  sensitive  membrane  which 
everywhere  lines  the  pulmonary  cells  are  spasmodically  contracted,  the  capacity 
of  the  chest  is  contracted,  expansion  of  the  lungs. is  prevented,  the  entrance  of 
sufficient  air  into  the  lung-cells  is  hindered,"  &c.  (Be  Asthmate  Convulsivo, 
1707.) 

In  studying  such  a  subject  as  this,  we  must  not  forget  to  consult  Whytt, 
who  in  so  many  points  was  in  advance  of  his  scientific  cotemporaries.  He 
defines  (Observations,  &c,  1764,  p.  260)  spasmodic  asthma  to  be — 

"That  species  of  difficult  breathing  which  is  not  owing  to  any  obstruction  in 
the  lungs,  or  load  of  humours  compressing  their  vessels,  but  to  an  uncommon 
contraction  of  their  bronchial  tubes  and  vesicles,  whereby  they  do  not  yield  as 
usual  to  the  pressure  of  the  air  in  inspiration." 

Cullen,  too,  a  few  years  later  (1772)  wrote,  "The  proximate  cause1  of 
this  disease  is  a  preternatural,  and,  in  some  measure,  a  spasmodic  constric- 
tion of  the  muscular  fibres  of  the  bronchiae." 

It  appears,  then,  that  from  the  time  of  Willis,  at  least,  the  distinction 
of  nervous  asthma  from  dyspnoea  produced  by  physical  causes  was  fully 
recognized,  and  that  during  nearly  the  first  half  of  the  present  century 
those  who  would  not  admit  it  to  be  a  disease  because  it  left  no  lesion  in 
the  body,  were  as  ignorant  of  the  subject  as  the  ancients  were,  but  without 
the  same  excuse  for  their  ignorance.  It  appears  further  that  they  who 
ascribe  our  more  accurate  knowledge  of  the  nature  of  asthma  to  the  dis- 


1863.] 


Salter,  Asthma. 


103 


covery  of  the  bronchial  muscles  by  Reisseissen,  or  other  cotemporary  anato- 
mists, are  but  imperfectly  acquainted  with  the  literary  history  of  asthmatic 
affections. 

It  is  unnecessary  to  enumerate  the  names  of  all  among  more  recent 
pathologists  who  have  taught  the  doctrine  that  nervous  asthma  depends 
on  bronchial  spasm.  But  some  of  them  may  be  referred  to.  Laennec 
(ii.  1*79)  says: — 

"When  full  inspirations  are  inadequate  to  make  the  air  reach  the  pulmonary 
vesicles,  the  fact  can  be  attributed  only  to  a  spasm  of  the  vesicles  themselves,  or, 
at  least,  of  the  small  bronchial  ramifications." 

The  same  doctrine  is  maintained  by  Georget,  Lefevre,  Copland,  Wun- 
derlich,  Grisolle,  Romberg,  Trousseau,  Walshe,  and  all  others  whose  con- 
clusions are  authoritative. 

It  may  be  proper  to  mention  that  Dr.  Budd  (Med.-Chir.  Trans.,  xxiii. 
62)  and  Dr.  Kidd  (Dub.  Quar.,  May,  1861,  p.  296)  attribute  the  pheno- 
mena of  asthma  to  spasm,  indeed,  but  spasm  of  the  external  muscles  of 
respiration.  It  is  sufficient  to  reply  that  the  external  muscles  are  not  in 
a  state  of  sustained  spasmodic  action  in  this  disease,  and  except  in  tetanus 
they  never  are.  In  a  word  their  contraction  during  the  asthmatic  paroxysm 
is  voluntary  and  intermittent,  while  the  dyspnoea  is  sustained  and  more  or 
less  permanent,  and  such  as  would  be  occasioned  by  involuntary  muscles  in 
spasmodic  action. 

As  we  have  seen,  among  the  objectors  to  the  theory  of  bronchial  spasm 
is  Dr.  Budd.  He  details  some  experiments  with  the  galvanic  apparatus 
applied  to  different  portions  of  the  air  tubes,  and  declares  that  no  contrac- 
tion can  be  produced  by  its  means  either  in  the  bronchial  tubes  or  in  the 
trachea.  He  also  quotes  the  experiments  of  Wedemeyer  to  the  same  pur- 
pose. But,  evidently,  by  proving  too  much  they  prove  nothing.  For  the 
merest  tyro  in  anatomy  can  demonstrate  the  muscularity  of  the  trachea. 

But  it  has  been  conclusively  shown  by  the  microscope  and  by  physio- 
logical experiment  that  the  bronchia  are  provided  with  muscular  and 
contractile  fibres.  Longet  (Physiol.,  i.  646,  1859),  after  detailing  some 
experiments  with  the  galvanic  current  on  the  pneumogastric  nerves,  and 
referring  to  the  investigations  of  Kolliker  and  Moleschott,  concludes 
not  only  as  to  the  certainty  of  the  existence  of  muscular  fibres  in  the 
minutest  bronchia,  but  also  as  to  the  probability  of  their  presence  in  the 
vesicular  structure.  He  even  maintains  that  such  a  supposition  is  neces- 
sary; for  the  act  of  expiration,  either  by  the  relaxation  of  the  inspiratory 
muscles  alone,  or  also  with  the  active  co-operation  of  the  external  expira- 
tory muscles,  would  be  unable  to  expel  the  mucus  or  even  the  foul  air  con- 
tained in  the  ultimate  bronchia.  Consequently,  he  argues,  these  bronchial 
and  vesicular  muscles  are  essential  to  the  renewal  of  the  air,  to  the  permea- 
bility of  the  bronchia,  and  the  maintenance  of  the  respiratory  function. 

Quite  recently  Dr.  Radcliffe  Hall  (Braith.  Retros.,  xlv.  t6),  without 
apparently  being  acquainted  with  Longet's  argument,  says: — 

"The  smallest  bronchial  tubes  are  the  most  muscular;"  "they  con- 
tract rhythmically  in  quiet  normal  respiration,  and  by  so  doing  quicken  the 
expulsion  of  foul  air  from  the  air-cells,  and  accommodate- the  size  of  the  tubes  to 
the  lessening  bulk  of  the  lungs." 

He  also  holds  that  they  contract  partially  towards  the  close  of  the  inspi- 
ratory act,  completing  the  propulsion  of  the  air  to  the  vesicles  which  the 
external  muscles  had  begun,  just  as  the  capillary  arteries  by  their  own  con- 


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tractility  propel  the  blood  further  which  they  received  from  the  action  of 
the  heart  and  larger  arteries. 

It  is  no  objection  to  this  view  that  it  implies  a  power  in  the  minute 
bronchia  of  propulsion  in  either  direction.  A  similar  power  is  exerted  by 
the  stomach  in  ordinary  vomiting,  and  by  the  small  intestine  when  the 
vomiting  is  stercoraceous ;  also  by  the  urethral  muscles  when  they  draw 
into  the  bladder  foreign  bodies  placed  in  the  urethra,  and  even  by  the  vagina 
and  uterus  when  they  carry  the  seminal  fluid  to  the  ovaria. 

Let  it  be  added,  however,  that  the  doctrine  of  Dr.  R.  Hall,  however  ori- 
ginal, is  not  new;  it  dates  really  from  the  last  century. 

In  IT 51  Whytt  (On  the  Vital  and  Involuntary  Motions  of  Animals, 
p.  170),  speaking  of  the  active  agents  in  respiration,  said  :  "The  muscular 
fibres  of  the  bronchia,  by  their  contractile  power,  contribute  to  the  expulsion 
of  the  air  out  of  the  lungs." 

To  return  from  this  digression.  Dr.  Salter  continues  his  demonstration 
by  showing  "  that  the  phenomena  of  asthma  are  those  of  excito-motory  or 
reflex  action."  Often  they  are  developed  by  a  mechanism  similar  to  that 
which  excites  cough,  the  presence  of  some  offeuding  agent  in  the  bronchia 
themselves,  as  various  effluvia,  dust,  and  other  minute  particles ;  more  fre- 
quently gastric  impressions  made  by  irritating  or  too  abundant  food ; 
sometimes  by  accumulated  fecal  matter ;  occasionally  by  a  remoter  im- 
pression still,  as  in  a  case  where  the  attacks  were  brought  on  by  the  ap- 
plication of  cold  to  the  instep.  In  some  rare  instances  the  source  of  irri- 
tation producing  the  paroxysm  appears  to  be  central,  as  when  an  attack 
has  preceded  brain  disease,  or  has  taken  the  place  of  habitual  epileptiform 
convulsions.  Cases  in  which  the  cause  of  the  attack  is  mental  are  evidently 
of  central  origin.  Much  importance  is  attached  by  the  author  to  the  hu- 
moral source  of  the  paroxysms  in  numerous  cases.  Besides  the  reflex 
operation  of  gastric  irritants  through  the  pneumogastric  nerve,  the  direct 
action  upon  the  nerves  of  the  lung  by  the  products  of  digestion  is,  in  his 
opinion,  to  be  charged  with  producing  asthmatic  attacks.  In  many  in- 
stances this  effect  appears  to  result,  not  from  any  intrinsically  noxious 
quality  of  the  articles  of  food  employed,  but  to  a  special  susceptibility  to 
be  influenced  by  some  which  are  in  themselves  perfectly  wholesome.  The 
same  peculiarity,  it  has  already  been  stated,  is  noticeable  in  regard  to 
effluvia.  The  articles  of  food  which  are  prone  to  produce  these  effects  are, 
iu  general,  such  as  are  crude  and  indigestible,  among  which  may  be  men- 
tioned cheese,  nuts,  raisins,  confectionery,  salted  and  highly  seasoned  food, 
and  fermented  drinks.  Dr.  Salter  meets  the  very  natural  objection  that 
these  ingesta  may  occasion  asthma  by  a  reflex  and  not  by  a  direct  action 
on  the  lungs,  by  stating  that  they  induce  asthma  in  just  such  time  as  they 
would  take  to  reach  the  lungs  subsequent  to  their  absorption,  and  that,  as 
a  general  rule,  in  persons  afflicted  with  an  appropriate  susceptibility,  the 
rapidity  with  which  the  attack  comes  on  depends  upon  the  facility  with 
which  the  particular  article  of  food  is  absorbed.  Thus,  in  a  case  which  is 
referred  to,  the  attack  always  followed  immediately  after  taking  wine  or 
any  alcoholic  drink  ;  while  in  another  the  food  producing  asthma  was  such 
as  would  furnish  material  for  lacteal  absorption,  and  the  attack  did  not 
come  on  until  two  hours  after  the  food  was  taken.  In  spite  of  these  cSses, 
the  author  is  careful  not  to  insist  too  strongly  on  the  humoral  origin  of 
asthmatic  attacks,  remembering  how  often  the  susceptibility  in  question  is 
associated  with  unquestionable  dyspeptic  disorder. 

We  cannot  better  conclude  our  notice  of  this  portion  of  Dr.  Salter's 


1863.] 


Salter,  Asthma. 


105 


Essay  than  by  stating,  in  the  author's  own  words,  the  connection  between 
the  muscularity  of  the  bronchial  tubes  and  the  phenomena  of  asthma. 

"The  purpose  of  this  muscular  furniture  of  the  bronchial  tubes  is,"  he  re- 
marks, "  that  they  should  contract  under  certain  circumstances,  and  on  the 
application  of  certain  stimuli ;  and  seen  by  this  light  we  recognize  in  asthma 
merely  a  morbid  activity — an  excess — of  this  natural  endowment;  the  tubes 
fall  into  a  state  of  contraction  with  a  proneness,  a  readiness,  that  is  morbid ; 
the  slightest  thing  will  throw  them  into  a  state  of  spasm,  the  irritability  of  the 
muscles  is  exalted,  the  contraction  violent  and  protracted,  that  becomes  a 
stimulus  to  contraction  which  should  not  be,  and  the  nervous  and  muscular 
system  of  the  lungs  is  brought  within  the  range  of  sources  of  irritation  applied 
to  such  distant  parts  as  ordinarily  in  no  way  affect  them.  Any  healthy  man 
may  have  his  bronchial  tubes  temporarily  thrown  into  a  state  of  asthmatic 
spasm  by  the  inhalation  of  ammoniacal  or  carburetted  or  other  irritating  gases  ; 
but  only  by  such  materials  whose  exclusion  is  necessary  for  the  safety  of  the 
lungs,  will  this  natural  asthma  be  brought  about.  A  greater  degree  of  bronchial 
sensibility  is  shown  in  those  cases,  by  no  means  uncommon,  of  what  is  called 
'hay-asthma,'  in  which  the  stimulus  to  bronchial  spasm  is  the  effluvium  of  hay; 
a  still  greater,  in  those  cases,  much  rarer,  in  which  the  emanations  from  ipeca- 
cuan  powder  will  at  once  give  rise  to  asthma ;  a  still  greater  in  that  numerous 
class  of  cases  of  asthma  in  which  the  disease  is  called  into  activity  by  certain 
atmospheric  peculiarities  which  are  altogether  inappreciable,  as  where  an  attack 
of  asthma  is  inevitably  brought  on  by  going  to  a  certain  place,  living  in  a  certain 
house,  sleeping  in  a  certain  room.  All  these  cases  fall  strictly  under  what  we 
may  call  the  formula  of  health ;  they  are  physiological ;  they  are  instances  of 
the  contraction  of  a  muscular  tube  in  obedience  to  stimulus  applied  to  the 
mucous  membrane  that  lines  that  tube1;  the  nervous  system  engaged  is  the 
intrinsic  nervous  system  of  the  tubes,  its  own  ganglia  and  perceptive  and  motor 
filaments,  in  the  same  way  as  in  oesophageal  deglutition  or  intestinal  peristaltis  ; 
the  error  is  merely  a  morbid  exaltation  of  a  normal  irritability.  But  there  are 
other  cases  in  which  the  error  is  more  than  this,  in  which  the  nervous  apparatus 
involved  in  the  phenomena  is  abnormally  extended  ;  in  which  certain  outlying 
and  distant  parts  of  the  nervous  system  are  the  recipients  of  the  stimuli  that 
give  rise  to  bronchial  spasm,  as  in  those  cases  to  which  I  have  referred,  where 
an  attack  is  induced  by  an  error  in  diet,  a  loaded  rectum,  the  application  of 
cold  to  the  instep,  mental  emotion ;  in  which  the  gastric  filaments  of  the  pneu- 
mogastric  nerves,  the  sympathetic,  the  cutaneous  nerves  of  the  foot  and  the 
brain,  are  respectively  the- recipients  of  the  stimulus  that  gives  rise  to  the  bron- 
chial contraction.  In  the  former  class  of  cases  the  bronchial  spasm  takes  place 
in  obedience  to  the  wrong  stimulus  applied  to  the  right  place ;  in  the  latter, 
place  and  stimulus  are  alike  wrong.  ...  In  what,  then,  does  the  peculiarity 
of  the  asthmatic  essentially  consist  ?  Manifestly,  in  a  morbid  proclivity  of  the 
musculo-nervous  system  of  his  bronchial  tubes  to  be  thrown  into  a  state  of 
activity  ;  the  stimulus  may  be  either  immediately  or  remotely  applied,  but  in 
either  case  would  not  normally  be  attended  by  any  such  result.  There  is  no 
peculiarity  in  the  stimulus  ;  .  .  .  nor,  probably,  is  there  any  peculiarity  in 
the  irritability  of  the  bronchial  muscle  ;  the  peculiarity  is  confined  to  the  link 
that  connects  these  two — the  nervous  system,  and  consists  in  its  perverted 
sensibility,  in  its  receiving  and  transmitting  on  the  muscle,  as  a  stimulus  to  con- 
traction, that  of  which  it  should  take  no  cognizance.  .  .  .  These  considera- 
tions, I  think,  tend  to  rationalize  our  notions  of  asthma,  and  to  impart  at  once 
an  interest  and  an  order  to  its  phenomena." 

The  clinical  history  of  asthma  is  very  fully  related  by  our  author,  and 
in  very  graphic  language,  but  our  limits  will  not  admit  of  any  extracts. 
Among  other  things,  he  dwells  upon  the  fact  that  the  attacks  so  generally 
commence  between  three  and  six  o'clock  in  the  morning,  illustrating 
the  supremacy  obtained  by  the  excito-motory  functions  during  the  suspen- 
sion of  the  will  by  sleep.    He  elsewhere  (p.  178)  points  out  the  degree  to 


106 


Reviews. 


[Jan. 


which  sleep  exalts  nervous  action.  He  has  omitted  noticing,  however,  one 
of  the  most  familiar  examples  from  this  class  of  facts,  the  occurrence  of 
spasmodic  croup  uniformly  at  night,  and  its  limitation  to  certain  families 
or  to  individual  members  of  such  families,  proving  that  in  this  disease,  as 
in  asthma,  a  special  susceptibility  is  usually  necessary  to  bring  on  an 
attack.  Occasional  exceptions  to  the  law  of  nocturnal  occurrence  of  the 
paroxysms  are  met  with.  M.  Trousseau  mentions  one  in  which  the  attacks 
came  on  uniformly  at  eight  o'clock  in  the  morning,. and  Dr.  Salter  relates 
the  singular  case  of  a  night  porter  who  slept  only  by  day,  but  who,  never- 
theless, had  his  fits  of  asthma  about  five  or  six  in  the  morning  when  he 
was  up  and  awake. 

Dr.  Salter  offers  some  remarks  in  regard  to  the  capacity  of  the  chest 
during  the  paroxysm,  which  have  induced  us  to  make  it  the  subject  of  a 
little  comparative  analysis.    His  statement  is  as  follows  (p.  75)  : — 

"  One  result  of  the  straining  efforts  to  fill  the  chest  is  a  permanent  distension 
of  it — its  walls  are  kept  fixed  in  a  condition  of  extreme  inspiration.  So  great^ 
is  the  enlargement  of  the  chest  during  the  paroxysm,  that  any  article  of  dress 
that  would  ordinarily  fit  the  waist  cannot  be  brought  together  by  two  inches. 
But  the  chest  is  enlarged  in  every  other  way,  the  diaphragm  therefore  descends, 
the  abdomen  therefore  seems  fuller,  and  its  girth  is  increased." 

One  of  the  most  eminent  of  German  physicians,  Wunderlich,  makes  a 
somewhat  similar  statement,  as  follows  : — 

"  Oue  form  of  asthma  consists  in  a  gradual  augmentation  of  the  dyspnoea, 
which  reaches  its  maximum  at  the  end  of  tivo  or  three  days.  At  this  stage  the 
chest  is  almost  motionless  in  spite  of  the  most  violent  muscular  efforts;  the  re- 
spiration rises  to  60  or  80  in  a  minute,  but  is  short  and  gasping  ;  coarse  sibilant 
and  sonorous  rhonchi  are  heard  all  over  the  lungs,  the  percussion  resonance 
is  everywhere  preserved,  and  after  many  hours  the  limits  of  the  chest  are  ex- 
tended downwards.  The  liver  also  descends,  the  heart  is  thrust  into  the  epigas- 
trium, and  the  thorax  is  excessively  distended."  (Pathologie,  iii.  316.) 

Grisolle  (Pathol,  int.  ii.  745)  says,  "  during  the  paroxysm  the  chest  is 
resonant,  often  unnaturally  so." 

Dr.  Kidd,  also  (Dublin  Quar.,  May,  '61,  p.  202),  intimates  that  authors 
who  have  made  a  contrary  statement  did  not  know  by  actual  observation 
what  they  were  talking  about,  and  assures  us  of  his  belief  that  a  contracted 
"  state  of  the  thorax  never  exists  in  spasmodic  asthma."  On  the  contrary, 
he  remarks,  "  the  thorax  is  distended  to  its  greatest  extent  .  .  .  .  so  as  to 
produce  great  fulness  of  the  abdomen,  and  cause  the  heart's  impulse  to  be 
felt  at  the  scrobiculus."  "  The  great  difficulty,"  he  concludes,  "is  to  empty 
the  chest." 

It  may  appear  singular  that  in  regard  to  a  point  of  simple  ocular  obser- 
vation there  should  be  a  divergence  of  opinion  amounting  to  contradiction 
among  different  medical  writers  upon  the  subject  of  asthma.  It  will  not  do, 
with  Dr.  Kidd,  to  say  that  successive  writers  have  copied  from  one  another. 
This  may  be  true  of  certain  among  them  who  compiled  what  they  read 
rather  than  described  what  they  saw ;  but  it  will  not  apply  to  the  greater 
number,  from  some  of  whom  the  following  citations  are  made. 

We  have  already  seen  that  Hoffmann  declares  the  capacity  of  the  chest 
to  be  contracted  during  the  paroxysm. 

Laennec  (ii.  386)  describes  the  percussion  resonance  as  very  moderate 
in  many  cases. 

Dr.  C.  J.  13.  Williams,  one  of  the  first  English  followers  of  Laennec, 
says : —  • 


1863.] 


Salter,  Asthma. 


107 


"  When  bronchial  spasm  is  considerable,  the  chest  may  sound  ill  on  percus- 
sion  with  a  short,  tight  sound  like  that  which  the  chest  yields  on  forced 

expiration.  This  is  caused  by  the  contracted  state  of  the  lungs  when  under  the 
influence  of  bronchial  spasm."  (Lib.  Pract.  Med.,  iii.  145.) 

Romberg  tells  us  (i.  328)  : — 

"  'The  patient  feels  that  the  air  does  not  pass  beyond  a  certain  point  of  his 
thorax.'  When  the  attack  ceases  suddenly,  '  the  air  rushes  violently  into  the 
bronchi  and  pulmonary  vesicles  into  which  it  had  previously  been  precluded 
from  entering,  and  a  puerile  murmur  is  produced.'  " 

Lebert  (ii.  38)  says :  "  During  the  attack,  the  percussion  pitch  is 
raised.'" 

Walshe  (p.  424)  declares  that  "  there  is  little  or  no  true  inspiratory 
expansion,"  and  "the  resonance  on  percussion  is  slightly  impaired." 
Finally,  not  to  multiply  citations,  Dr.  Flint  (p.  391)  makes  the  follow- 
ing explicit  statement :  "If  emphysema  be  not  present,  the  volume  of  the 
lungs  may  be  reduced  by  the  expiratory  efforts  so  as  to  diminish  appreciably 
the  clearness  on  percussion." 

These  authors  are  all  original  observers,  and  of  the  first  rank,  and  yet 
they  agree  in  making  statements  to  wmich  that  of  Salter,  Wunderlich, 
Grisolle,  and  Kidd  are  diametrically  opposed.  Now,  it  would  seem  almost 
certain  that  on  the  one  side  or  the  other,  there  had  either  been  an  error  of 
observation,  or  in  the  statement  of  its  results.  On  the  one  hand,  increased 
percussion  resonance  has  certainly  existed,  but  on  the  other  hand,  in  a  dif- 
ferent set  of  cases,  it  has  not  been  present.  The  passage  that  has  been 
quoted  above  from  Wunderlich  probably  explains  in  some  degree  this  con- 
trariety of  statements.  This  author  mentions  that  after  two  or  three  days 
of  asthma  distention  of  the  thorax  is  observed.  The  persistent  and  pro- 
longed struggle  to  inspire  air  tends,  by  straining  the  pulmonary  tissue,  to 
dilate  the  vesicles  and  expand  the  chest;  and,  however  ineffectual  this  effort 
to  inspire  may  be  at  the  commencement  of  the  paroxysm,  successive  repeti- 
tions of  the  act  may  add  to  the  amount  of  air  locked  up,  and,  if  the  attack 
be  a  long  one,  gradually  distend  the  lungs  and  render  the  chest  resonant 
upon  percussion,  where  it  had  previously  exhibited  diminished  resonance. 
If,  then,  there  are  any  cases  in  which  at  the  commencement  of  a  paroxysm  the 
percussion  resonance  is  unnaturally  great,  there  would  seem  to  be  a  strong 
probability  that  they  present  the  complication  of  emphysema  ;  and  if  this 
supposition  is  correct,  dilatation  of  the  chest  is  not  a  characteristic  symp- 
tom of  pure  nervous  asthma. 

That  it  is  probably  correct  may  be  inferred  from  the  extreme  rarity  of 
pure  nervous  asthma.  It  is,  in  fact,  one  of  the  rarest  among  diseases  of 
the  lungs.    Thus,  Laenneo  (op.  cit.,  p.  385)  declares — 

"I  have  found  evidence  of  pulmonary  spasm  in  a  very  small  proportion  of 
asthmatic  patients  independently  of  all  complication  with  pulmonary  catarrh. 
Nevertheless,  I  am  able  to  affirm  that  this  condition  exists." 

Wunderlich  informs  us  (op.  cit.,  p.  312)  that,  in  the  course  of  six 
years,  he  found  but  three  cases  of  it  among  ten  thousand  clinical  patients. 

Yalleix  (Guide  du  Med.,  ii.  562)  remarks  that,  "in  the  Parisian 
hospitals,  where  pulmonary  diseases  are  so  carefully  studied,  cases  of  nervous 
asthma  are  almost  never  met  with." 

Sandras,  in  his  treatise  on  Nervous  Diseases  (ii.  148),  after  describing 
some  cases  of  the  affection,  says  :  "  These  exceptional  cases  constitute  ner- 
vous asthma." 


108 


Reviews. 


[Jan. 


And,  finally,  Dr.  Salter,  himself,  remarks : — 

"  Cases  of  perfectly  pure  asthma,  that  is,  without  the  slightest  organic  com- 
plication, are,  however,  rare,  unless  they  have  existed  a  very  short  time,  and  for 
this  reason— that  asthma,  if  it  is  at  all  severe  and  its  attacks  frequent,  cannot 
long  exist  without  inflicting  permanent  injury  on  the  lungs,  and  even  on  the 
heart:' 

We  cannot  follow  Dr.  Salter  in  his  further  analysis  of  the  phenomena  of 
the  asthmatic  paroxysm,  but  merely  remark  that  it  displays,  like  the  rest 
of  his  pathological  disquisitions,  great  familiarity  with  the  phenomena  of 
the  disease  and  accurate  reasoning  from  them.  Nor  can  we  dwell  upon 
his  interesting  illustrations  of  the  periodicity  of  the  attacks. 

We  merely  note,  in  passing,  his  statement,  that  their  diurnal  occurrence 
furnishes  good  grounds  for  suspecting  that  they  rest  upon  an  organic  basis, 
and  also  his  confirmation  of  the  general  testimony  of  authors  that  the 
attacks  are  more  frequent  in  summer  than  in  winter.  The  periodicity  of 
asthma,  he  remarks,  is  of  two  kinds ;  that  which  depends  upon  the  periodi- 
cal recurrence  of  its  evident  exciting  cause,  and  that  which  appears  to  be 
intrinsic,  or,  in  other  words,  independent  of  external  circumstances. 

It  appears,  as  indeed  seems  but  natural,  that  the  cases  which  come  on 
in  youth  and  in  early  manhood,  are  generally  specimens  of  the  pure  spas- 
modic form  without  organic  complication,  and,  moreover,  that  they  are 
usually  examples  of  the  hereditary  transmission  of  the  affection.  According 
to  Dr.  Salter's  observation,  twice  as  many  males  have  asthma  as  females. 
We  notice  that  Frank  gives  the  proportion  as  much  larger,  viz.,  as  six  to 
one. 

The  immediate  or  exciting  causes  of  asthmatic  attacks,  are  generally 
direct  irritants  inspired ;  alimentary  irritants ;  remote  sources  of  nervous 
irritation,  and  psychical  irritants.  Examples  of  each  of  these  will  occur  to 
every  reader.  The  essential  causes,  our  author  concludes,  may  be  organic 
lesions,  perhaps  inappreciable,  either  in  the  bronchial  tubes  or  in  some 
part  physiologically  connected  with  them ;  or  else,  may  consist  of  some 
congenital,  possibly  inherited,  peculiarity  of  constitution,  whose  nature  it 
is  not  possible  for  us  at  present  to  apprehend.  It  may  be  urged,  we  think, 
that  an  "inappreciable  organic  lesion"  is,  practically,  something  difficult  to 
distinguish  from  an  "idiosyncrasy."  It  is  easy  to  believe  that  a  certain 
palpable  lesion  or  peculiar  organic  condition  may  be  an  efficient  cause  of 
asthma  ;  but  if  a  lesion  ceases  to  be  appreciable,  it  also  ceases  to  give  proof 
that  it  exists.  In  the  illustrations  adduced  by  the  author,  the  existence  of 
a  lesion  is  inferred,  but  not  proved. 

Although  asthma  never  kills,  it  may,  according  to  our  author,  produce 
certain  organic  changes  in  the  heart  and  lungs  which  ultimately  prove 
fatal.  Repeated  paroxysms  may  occasion  hypertrophy  of  the  bronchial 
muscles,  and  thus  diminish  the  calibre  of  the  tubes,  and  the  bronchitis  which 
so  generally  complicates  the  spasmodic  affection  must  still  further  lessen 
the  supply  of  air  in  respiration.  It  is  also  remarked,  that  the  greater  or 
less  degree  of  asphyxia  existing  during  the  paroxysm  shows  that  the  pul- 
monary circulation  is  overloaded ;  serous  effusion  takes  place  constituting 
oedema  of  the  lungs,  and  the  right  side  of  the  heart  becomes  dilated  and 
hypertrophied.  Associated  with  or  following  these  effects  emphysema  is 
developed.  This  last  result  is  ascribed  to  the  strain  upon  those  pulmonary 
lobules  to  which  the  air  has  access,  while  the  rest  are  closed  by  spasm  or 
obstructed  with  mucus.  It  is  to  be  observed  that  all  the  elements  here  re- 
ferred to,  except  bronchial  spasm,  are  characteristic  not  of  asthma  but  of  * 


1863.] 


Salter,  Asthma. 


109 


emphysema  following  or  accompanying  bronchitis  independently  of  any 
asthmatic  complication.  To  explain  through  them  the  development  of 
emphysema  in  asthmatic  persons,  is  clearly  to  interpolate  causes  with  which 
asthma  has  no  necessary  connection,  and  which  of  themselves  are  quite 
sufficient  to  develope  emphysema  of  the  lungs,  if  an  organic  predisposition 
to  that  disease  exists.  It  is  true,  that  Dr.  Salter  speaks  of  having  "  seen 
emphysema  developed  in  a  case  of  asthma  in  which  bronchitis  never  existed." 
Yet  it  is  certain  that  the  latter  disease  is  not  unfrequently  the  precursor  of 
emphysema,  while  pure  asthma  is  very  rarely,  if  ever  so  ;  hence,  we  cannot 
admit  any  direct  causative  connection  between  the  nervous  and  the  organic 
affection.  But,  still  further  than  this,  emphysema  is  by  no  means  confined 
to  cases  in  which  either  asthma,  or  bronchitis,  or  heart  disease,  has  previ- 
ously existed  ;  it  more  frequently  arises  spontaneously.  This  is  a  fact  long 
ago  insisted  upon  by  Louis,  who,  as  well  as  other  writers,  has  also  shown 
that  the  disease  is  very  often  hereditary,  and  independent  of  all  exciting 
causes,  and  particularly  of  pulmonary  catarrh.  It  would  appear  most  proba- 
ble that  emphysema  is  produced  by  organic  conditions  involving  a  diminution 
of  muscular  power  rather  than  an  excess  of  it ;  first,  because  it  oftenest 
arises  without  any  strain  from  cough  or  dyspnoea;  and  secondly,  because, 
when  bronchitis  precedes  it,  the  mucous  and  muscular  coats  of  the  bronchia 
must  lose  contractile  power  instead  of  gaining  it.  It  is  also  important  to 
remark  that  emphysema  could  not  be  produced  by  asthma  unless  the  habi- 
tual state  of  the  lungs  during  the  paroxysm  were  one  of  extreme  distention. 
So  long  as  the  chest  remains  contracted,  the  strain  upon  the  vesicles,  far 
from  being  increased,  is  really  less  than  usual ;  and  it  is  only  towards  the 
end  of  prolonged  paroxysms  that  the  vesicular  structure  can  become  dilated. 
We  have  endeavoured  to  prove  that  constriction,  and  not  expansion,  is  the 
ordinary  state  of  the  chest  during  the  attack,  and  the  bearing  of  this  pro- 
position upon  the  relation  of  emphysema  to  asthma,  will  be  now  apparent. 

In  considering  the  treatment  of  asthma,  Dr.  Salter  first  mentions  the 
depressants  ipecacuanha,  tartar  emetic,  and  tobacco,  of  which  he  regards 
the  last  as  the  most  speedy  and  effectual.  They  afford  relief  by  relaxing  the 
bronchial  spasm,  and  terminating  it  by  reducing  the  power  which  generates 
it.  Stimulants,  on  the  other  hand,  put  an  end  to  the  attack  by  exalting 
the  nervous  energy  above  the  point  at  which  the  reflex  susceptibility,  on 
which  the  spasm  depends,  has  a  tendency  to  display  its  power  in  producing 
muscular  contraction.  That  involuntary  and  spasmodic  muscular  action  has 
a  peculiar  tendency  to  take  place  during  sleep,  the  time  when  the  asthmatic 
paroxysm  usually  occurs,  has  already  been  referred  to  as  a  physiological  fact. 
Hence  we  may  explain  the  usefulness  of  coffee,  tea,  alcohol,  ammonia,  canna- 
bis, ether,  and  other  nervous  stimulants  in  preventing  the  attacks.  Of  these, 
the  most  favourable  judgment  is  given  for  coffee.  Under  the  title  of  "seda- 
tives," as  distinguished  from  "depressants,"  the  author  refers  again  to 
tobacco,  Indian  hemp,  opium,  and  stramonium.  Undoubtedly  these  medi- 
cines are  sedatives  of  abnormal  nervous  action,  but,  except  in  poisonous 
doses,  they  are  stimulants,  and,  in  virtue  of  their  stimulant  action,  assuage 
morbid  nervous  action  precisely  as  alcohol  allays  the  "horrors"  of  the 
drunkard,  or  quiets  the  jactitation,  subsultus,  and  tremors  of  typhus  fever. 

Chloroform  belongs  to  the  same  category.    It  is  by  its  primary  and 
stimulant  operation,  and  when  it  is  administered  in  small  doses,  that  it  so 
marvellously  arrests  the  paroxysm  of  nervous  asthma.    A  case  is  mentioned 
I  by  Dr.  S.  in  which  a  few  whiffs  of  chloroform  sufficed  to  afford  relief,  and, 
before  insensibility  was  produced,  the  breathing  was  free.    Where  a  marked 


110 


Reviews. 


[Jan. 


bronchitic  affection  exists,  the  full  influence  of  the  medicine  would  manifestly 
be  dangerous.  Objection  is  made  to  the  use  of  opium  in  this  disease,  and 
we  think  with  reason.  Its  stimulant  operation  can  scarcely  be  obtained 
without  being  speedily  followed  by  its  narcotic  action,  and  this  teuds  to 
embarrass  rather  than  to  relieve  the  respiratory  organs.  In  the  use  of 
stramonium,  the  author  does  not  appear  to  have  had  much  experience,  nor 
to  have  formed  as  high  an  estimate  of  its  virtues  as  they  deserve.  Of 
lobelia,  he  confesses  that  he  has  nothing  to  say;  and  the  little  that  he  says 
of  sulphuric  ether  is  unfavourable.  The  inhalation  of  the  fumes  of  burning 
nitre  paper  is  a  method  not,  indeed,  originating  with  himself,1  but  one  more 
fully  tested  by  him  than  by  any  person  who  has  published  his  experience  in 
the  treatment  of  asthma.  It  is  evidently  his  favourite  remedy.  Its  value, 
he  remarks,  is  in  proportion  to  the  purity  of  the  asthma ;  that  is  to  say, 
its  freedom  from  organic  complications.  It  was  of  little  use,  he  found, 
when  the  case  was  complicated  with  bronchitis.  He  advises  the  following 
mode  of  preparing  and  using  it : — 

"Dissolve  four  ounces  of  saltpetre  in  half  a  pint  of  boiling  water;  pour  the 
liquor  into  a  small  waiter,  just  wide  enough  to  take  the  paper ;  then  draw  it 
through  the  liquor  and  dry  it  by  the  fire;  cut  it  into  pieces  about  four  inches 
square,  and  burn  one  or  two  pieces  in  the  bedroom  on  retiring  to  rest  at  bed- 
time." 

The  paper  should  be  unsized,  porous,  and  not  containing  wool.  Red 
blotting-paper,  of  moderate  substance,  is  recommended. 

Dr.  Salter  lays  down  the  proposition  that  asthmatics  are  generally  dys- 
peptics in  a  greater  or  less  degree,  and  furnishes  some  illustrations  of  the 
influence  exercised  by  a  disordered  stomach  upon  the  recurrence  of  the 
attacks,  and  especially  of  the  mischief  occasioned  by  late  and  abundant 
dinners.  In  this  connection,  he  reminds  us  again  of  the  greater  liability 
which  exists  during  sleep  to  all  excito-mqtory  impressions,  and  especially 
to  those  which  originate  in  the  stomach.  All  of  his  precepts  are  sound, 
and  they  possess,  what  should  have  been  more  distinctly  recognized,  the 
sanction  of  long  .and  universal  experience.  Floyer,  in  his  chapter  on  this 
subject,  says  emphatically:  "Asthmatics  .are  best  fasting,  and  under  very 
frugal  and  simple  diet." 

One  of  the  most  interesting  chapters  of  the  present  treatise  is  "On  the 
Therapeutical  Influence  of  Locality."  It  is  there  shown  by  a  number  of 
cases  that  a  very  large  proportion  of  the  asthmatics  who  come  from  the 
country  to  London  are  relieved  during  their  residence  in  that  city.  The 
most  general  principles,  or  rules  rather,  which  he  believes  to  be  deducible 
from  experience  in  this  matter  are — 

"That  the  localities  that  are  the  most  beneficial  to  the  largest  number  of 
cases  are  large,  populous,  and  smoky  cities;"  and  "that  the  worse  the  air  for 
the  general  health,  the  better,  as  a  rule,  for  asthma;  thus,  the  worst  part  of 
cities  are  the  best,  and  conversely." 

To  these  rules,  however,  the  exceptions  are  numerous,  and  it  is  no 

1  The  first  published  account  of  this  treatment  that  we  have  met  with  is  con- 
tained in  the  New  York  Med.  Gaz.,  i.  375.  It  was  copied  into  this  Journal  (Jan. 
1842,  p.  262),  and  the  editor  subjoins  :  "We  can  add  our  testimony  to  the  utility, 
in  some  cases,  of  this  remedy.  We  have  several  times  prescribed  it,  and  in  some 
instances  the  relief  it  afforded  seemed  almost  magical  ;  in  others,  however,  it 
entirely  failed."  A  subsequent  reference  to  the  medicine  is  contained  in  the 
London  Lancet,  1845,  i.  383,  and  ascribes  the  writer's  knowledge  of  the  remedy  to 
a  paragraph  accidentally  seen  in  a  newspaper. 


1863.] 


Salter,  Asthma. 


Ill 


uncommon  thing  to  find  that  a  particular  locality  as  certainly  prevents  the 
paroxysms  in  one  person  as  it  excites  them  in  another.  Floyer  suffered 
asthma  from  childhood  until  he  went  from  his  home  in  Staffordshire  to 
Oxford,  where  he  resided  for  twelve  years  without  any  considerable  fit.  He 
also  remarked  the  greater  immunity  of  asthmatics  from  their  fits  in  towns, 
but  thought  them  more  severe  when  they  did  happen.  A  similar  result  of 
his  own  observation  is  given  by  Trousseau.  We  believe  that  the  rule  also 
holds  in  this  country.  Upon  this  subject  we  need  make  no  apology  for 
quoting  the  following  passage  from  the  writings  of  one  of  our  most  saga- 
cious and  experienced  physicians,  the  late  Professor  Chapman  : — 

"  The  pure  air  of  the  country,  especially  in  elevated  positions,  I  have  found, 
with  very  few  exceptions,  more  pernicious  than  that  of  cities,  and  even  the 
suburbs  of  these  less  propitious  than  the  central  and  populous  parts.  Many 
instances  have  come  under  my  own  view  of  persons  affected  in  this  way,  who, 
very  comfortable  in  the  latter,  were  rendered  otherwise  in  the  former  situation, 
among  which  is  that  of  a  friend  of  mine  who  can  seldom  walk  to  the  edge  of  the 
city  with  impunity,  and  never  goes  into  the  country  without  an  attack.  It 
sometimes  happens,  too,  that  individuals  may  spend  the  day  comfortably  in  any 
rural  position,  though  on  the  approach  of  evening  they  are  unavoidably  seized. 
Three  or  four  instances  of  the  kind  I  have  known,  and  of  which  there  is  now 
living  in  Baltimore  a  gentleman  by  whom  I  am  informed  the  fact  is  strikingly 
illustrated  in  himself.  Close  to  the  town  he  owns  a  villa  remarkable  for  its 
general  healthiness,  at  which  he  has  not  slept  for  many  years  on  this  account — 
escaping,  however,  all  intimations  of  an  attack  during  the  clay."  [Lectures  on 
the  Diseases  of  the  Thoracic  and  Abdominal  Viscera,  1844.) 

The  beneficial  influence  of  sustained  bodily  exertion  is  insisted  upon  very 
strongly  by  our  author.  This,  too,  is  held  by  Floyer  to  be  an  essential  part 
of  the  treatment,  for  he  assures  us  that  "they  who  use  no  exercise  in  the 
intervals  of  the  fits  soon  fall  into  cachexias,  lethargies,"  &c. ;  and  he  ad- 
vises "riding,  sawing,  bowling,  ringing  of  a  dumb-bell,"  &c.  The  avoid- 
ance of  cold  and  dampness,  and  especially  of  the  breathing  of  damp  cold 
air,  is  very  properly  dwelt  upon  by  Dr.  Salter  as  closing  one  of  the  principal 
avenues  through  which  attacks  of  the  disease  come  on. 

By  a  singular  oversight,  the  author  states  that  he  is  not  sure  that  the 
inhalation  of  oxygen  gas  has  ever  been  tried.  Its  use  in  asthma  by  Hill,  in 
1800,  is  mentioned  in  so  familiar  a  text -book  as  Pereira's  Materia  Medica; 
it  had  still  earlier  been  recommended  by  Beddoes  and  Watt  in  their  treatise 
on  Factitious  Airs ;  Chaptal  and  also  Fourcroy  tried  it  in  asthma  ;  the 
authors  of  the  Compendium  de  Medecine  Pratique  remark  that  "this 
agent,  which,  on  theoretical  grounds,  should  have  been  very  efficacious,  has 
not  fulfilled  the  hopes  which  were  entertained  of  it,"  and  the  late  Dr.  Chap- 
man said  of  it,  "it  is  dead,  and  gone  to  the  'tomb  of  all  the  Capulets.'  " 

The  prognosis  in  spasmodic  asthma  is,  according  to  Dr.  Salter,  generally 
favourable  in  young  patients,  but  it  grows  less  favourable  with  advancing 
age.  It  need  scarcely  be  added  that  the  prospect  of  recovery  is  very  much 
clouded  by  the  presence  of  any  permanent  complication  either  of  the  lungs 
or  heart.  The  length  of  the  attacks,  their  frequency,  the  rapidity  and 
completeness  of  recovery  from  them,  their  tendency  to  increase  or  diminish 
in  number,  and  the  possibility  of  discovering  their  immediate  exciting 
causes,  are  all  to  be  taken  into  the  account,  precisely  as  they  should  be  in 
any  other  spasmodic  disease. 

From  the  preceding  survey,  the  reader  maybe  enabled  to  form  some  idea 
of  the  substance  and  manner  of  Dr.  Salter's  treatise,  but  not  such  an  one 
as  to  dispense  him  from  the  obligation,  or  to  tempt  him  from  the  pleasure, 


112 


Reviews. 


[Jan. 


of  studying  the  original.  It  abounds  in  the  fruits  of  original  observation; 
its  descriptions  are  full  and  lifelike;  its  reasoning  is,  for  the  most  part, 
cogent  and  satisfactory ;  and  its  style  is  remarkably  fresh,  sprightly,  and 
clear.  If  a  second  edition  should  be  published,  we  shall  hope  to  find  in  it 
more  frequently  due  credit  given  to  the  older  writers  for  the  essential  agree- 
ment of  their  views  with  those  which  Dr.  Salter  has  so  fully  and  perspicu- 
ously expressed.  A.  S. 


Art.  XVII. — General  Report  of  the  Commission  appointed  for  Improving 
the  Sanitary  Condition  of  Barracks  and  Hospitals.  (Presented  to  both 
Houses  of  Parliament  by  command  of  Her  Majesty.  1861.) 

A  recent  report  of  a  royal  commission  on  the  sanitary  state  of  the  army 
having  shown  that  the  annual  deaths  among  all  arms  on  home  stations  had 
reached  the  great  height  of  17.5  per  1000,  whereas  the  mortality  among 
males  Of  the  same  ages,  in  the  town  and  country  population  of  England 
and  Wales,  was  at  the  same  time  only  9.2  per  1000  (little  more  than  one- 
half),  another  commission  was  appointed  by  the  Secretary  of  War,  consist- 
ing of  Dr.  John  Sutherland,  W.  H.  Burrell,  and  Douglas  Galton,  engi- 
neers, to  inquire  into  the  causes  of  this  excessive  death-rate,  and  to  devise 
means  for  their  removal. 

For  this  purpose,  they  were  commanded  to  "examine  and  inquire  into 
the  sanitary  condition  of  all  barracks  and  military  hospitals  in  the  United 
Kingdom,  as  regards  their  position,  neighbourhood,  construction,  drainage, 
water  supply,  lavatories,  laundries,  baths,  kitchens,  water-closets,  latrine 
arrangements,  urinals,  means  of  ventilation,  lighting  and  warming,  both 
by  day  and  by  night,  the  dimensions  of  the  barrack-rooms  and  sick  wards, 
the  arrangements  of,  and  the  distance  between,  the  beds,  the  supply  of  bed- 
ding and  utensils,  the  amount  of  cubic  space  per  bed  in  barracks  and  hos- 
pitals, the  state  of  repair  of  the  buildings,  the  condition  as  to  cleanliness 
of  wards,  barrack-rooms,  and  other  buildings,  and  of  their  vicinity ;  and 
into  all  other  matters  connected  with  the  buildings  which,  in  your  opinion, 
may  be  prejudicial  to  the  health  of  the  soldier." 

In  addition  to  this  important  inquiry,  the  commission  were  enjoined  to 
"  devise  the  necessary  works  and  measures  required  for  removing  defects  in 
the  drainage,  for  the  abolition  of  cesspools,  for  the  formation  of  improved 
drainage,  for  improvements  in  water-closets,  latrines,  and  urinals,  for  pro- 
viding lavatories,  baths,  and  laundries,  for  thoroughly  and  efficiently  venti- 
lating all  barrack  -rooms,  wards,  and  day -rooms,  for  warming  and  lighting 
by  day  and  night,  and  for  improving  the  kitchens  in  all  barracks  and 
hospitals." 

They  were  further  instructed  to  allot,  whenever  practicable,  in  barracks 
and  guard-rooms,  not  less  than  600  cubic  feet  to  each  man,  and  three  feet 
to  intervene  between  every  two  beds;  while  in  hospitals,  1200  cubic  feet 
were  to  be  allowed  for  each  bed,  four  feet  between  the  sides  of  the  beds, 
and  twelve  feet  from  foot  to  foot,  when  practicable. 

These  instructions,  thorough  and  minute  in  every  hygienic  particular, 
were  coupled  with  authority  to  expend  a  sum  not  exceeding  £100  for  each 
hospital  or  barrack  so  inspected;  and,  whenever  that  sum  was  insufficient, 


1863.] 


Report  of  the  Sanitary  Commission. 


113 


they  were  to  make  estimates  and  plans,  to  be  submitted  to  the  proper  de- 
partment for  examination  and  allowance. 

With  these  very  liberal  and  praiseworthy  powers,  the  commission  imme- 
diately proceeded  to  the  work,  and  the  result  of  their  labours  is  exhibited 
in  the  book  before  us. 

The  total  number  of  barracks  in  the  United  Kingdom,  to  which  their 
inquiry  referred,  amounts  to  243,  of  which  162  were  personally  examined 
and  reported  for  improvements;  of  hospitals,  there  are  161,  of  which  114 
were  personally  inspected  and  reported  on.  The  remaining  barracks  (81) 
and  hospitals  (53)  are  nearly  all  small,  with  accommodations  for  few  men 
only;  the  inspection  of  and  report  upon  these  were  left  to  a  subsequent  pe- 
riod, in  order  not  to  delay  the  improvements  which  were  found  to  be  greatly 
needed  in  the  larger  and  more  important  places.  A  general  remark  made 
by  the  commission,  with  reference  to  the  financial  limit  to  which  they  were 
restricted  in  executing  sanitary  improvements,  is  worthy  of  note,  as  one 
which  might  have  been  expected  after  the  statement  of  the  great  mortality 
of  the  army  at  home  in  a  time  of  peace. 

"The  amount  of  funds  placed  at  our  disposal — namely,  £100  per  barrack — 
was  found  to  be  totally  inadequate  even  for  the  more  urgent  sanitary  works, 
because,  although  large  sums  of  money  have  been  from  time  to  time  spent  on 
these  barracks  and  hospitals,  a  very  small  portion  of  it  appears  to  have  been 
devoted  to  sanitary  purposes.  So  far,  indeed,  as  concerns  the  health  of  the 
troops,  almost  every  barrack  and  hospital  we  have  visited  can  be  considered  in 
no  other  light  than  as  never  having  been  completed.  * '  *  -  *  *  In  every 
instance,  therefore,  we  have  been  under  the  necessity  of  having  estimates  pre- 
pared for  sanitary  works." 

Such  is  the  care  which  the  government  of  Grea't  Britain  has  been  wont 
to  bestow  upon  its  immediate  dependents — an  almost  total  neglect  of,  next 
to  feeding  and  clothing,  the  first  essentials  of  health  and  life  ;  and  the  con- 
sequence has  been  a  mortality  nearly  double  that  which  the  men  would  have 
experienced  had  they  remained  civilians,  and  pursued  their  ordinary  indus- 
trial avocations.  An  analysis  of  the  diseases  which  led  to  this  high  rate 
of  mortality  demonstrated  that  the  excess  of  deaths  was  due  almost  entirely 
to  zymotic  diseases,  such  as  fevers,  cholera,  diarrhoea,  and  to  chest  and 
tubercular  diseases,  such  as  consumption,  &c.  Seven-ninths  of  the  entire 
mortality  among  the  infantry  of  the  line  were  found  to  arise  from  these 
two  classes  of  diseases ;  and,  for  each  class,  the  mortality  among  the 
infantry  was  shown  to  be  more  than  double  what  it  is  among  males  of  the 
same  ages  in  civil  life.  Can  any  circumstance  be  mentioned  more  damaging 
to  the  character  of  the  English  government  for  humanity  and  common 
sense  ? 

Nor  can  we  be  surprised  at  this  result,  when  we  have  learned  the  details 
of  the  unsanitary  condition  of  these  homes  of  the  soldier,  as  they  are  set 
forth  in  this  interesting  volume.  With  regard  to  the  position  and  neigh- 
bourhood of  barracks,  the  whole  number  is  divisible  into  two  classes.  1st. 
Those  which  are  situated  in  the  suburbs  of  towns,  in  positions  hardly  any 
of  which  can  be  said  to  be  unhealthy,  while  very  many  of  them  cannot  be 
described  as  otherwise  than  healthy;  sometimes  elevated  above  the  neigh- 
bouring levels,  with  sufficient  fall  for  drainage  ;  sometimes  occupying  lofty 
eminences,  fully  exposed  to  the  winds.  This  class,  it  is  said,  comprises  by 
far  the  greater  number  of  barracks  inspected.  The  2d  class  consists  of 
those  situated  in  or  near  densely-populated  neighbourhoods,  and  closely  sur- 
rounded by  dwellings  of  the  civil  population.  Of  these,  several  instances 
No.  LXXXXX.— Jan.  1863.  8 


114 


Reviews. 


[Jan. 


are  quoted;  some  inclosed  within  lofty  walls  in  such  a  manner  as  to  keep 
the  air  about  them  stagnant  at  all  ordinary  times.  Portman  Barrack,  for 
example,  "is  a  closed  square  of  two-story  buildings,  with  regulation  space 
for  483  men,  surrounded  on  all  sides  by  higher  walls,"  and  having  within 
cubic  space  for  only  276,  or  a  little  more  than  one-half  the  required  amount. 

"  Not  unfrequently,  barrack-rooms  are  built  close  to  the  privies  of  adjoining 
houses,  and  nuisance  is  experienced  in  the  barrack-rooms."  "  Ship  Street  Bar- 
rack, Dublin,  overlooks  a  street  of  filthy  houses,  behind  which  pigs  are  kept, 
and  nuisance  is  experienced  when  the  sties  are  cleaned."  "  Piershill  Barrack 
and  hospital,  near  Edinburgh,  is  in  an  open  situation,  but  in  the  immediate 
vicinity  of  meadows  irrigated  by  the  sewage  of  the  town."  "  Tilbury  Fort  is 
surrounded  by  a  wet,  undrained,  marshy  district  of  country,  particularly  exposed 
to  malaria ;  and,  whenever  it  is  occupied,  a  large  proportion  of  the  men  are  sure 
to  find  their  way' into  hospital  from  intermittent  fever." 

As  a  striking  instance  of  the  influence  exerted  upon  the  health  of  the 
soldier  (as  well  as  of  all  other  people)  by  the  locality  of  their  residence,  the 
contrast  is  drawn  between  the  average  mortality  of  all  arms,  previous  to 
1853 — which,  as  already  stated,  was  17.5  per  1000  per  annum — and  that 
at  Aldershot  and  Shorncliffe,  where  the  troops  were  encamped  in  an  open 
country.  In  the  three  years  ending  Dec.  31,  1859,  the  mortality  among 
them  was  only  4.7  per  1000  per  annum — about  one-quarter. 

The  construction  of  barracks  next  claims  attention,  and  in  this  respect 
it  is  stated  that  they  exhibited  great  diversity  of  plan,  and  still  greater 
diversity  in  internal  arrangements  and  proportions.  While  some  of  the 
plans,  especially  those  of  certain  Irish  barracks,  are  good,  convenient,  and 
well  adapted  to  health,  "  of  the  great  majority,  the  plans  are  very  indifferent, 
and  there  are  not  a  few  of  which  the  plans  or  construction,  or  both,  are 
essentially  bad."  The  attributes  of  a  healthy  barrack  appear  hardly  to 
have  been  considered;  facility  of  supervision  and  of  discipline,  and  the 
amount  and  shape  of  the  ground  at  the  disposal  of  the  architect,  seeming 
to  be  the  only  guides  in  their  arrangement,  and,  what  is  more  remarkable 
still,  "the  best  barracks  are  not  those  of  recent  construction,  but  are  found 
among  the  Irish  barracks  built  in  the  end  of  the  last  century  or  early  in 
the  present  one." 

As  a  specimen  of  defective  arrangement,  a  figure  of  the  ground-plan  of 
Hyde  Park  Cavalry  Barracks  is  given.    These  were 

"Constructed  to  accommodate  536  non-commissioned  officers  and  men,  with 
a  proportionate  number  of  horses,  on  a  long  strip  of  ground  3  acres,  2  roods,  35 
perches  in  extent.  The  buildings  for  men  and  horses  are  crowded  into  three 
acres  of  the  area,  which,  if  the  barracks  were  fully  occupied,  would  equal  a 
density  of  population  of  114,560  to  the  square  mile,  exclusive  of  women,  and 
children,  and  horses.  The  actual  number  in  barracks  when  we  inspected  them 
was  885. besides  women  and  children.  The  situation  towards  the  park  is  open; 
but  it  will  be  seen. that  there  are  fourteen  blocks  of  buildings  on  the  ground,  so 
disposed  as  effectually  to  cut  off  free  air  currents  from  the  square.  There  are 
do  back  premises,  and  the  litter  and  manure  are  thrown  out  directly  under  the 
windows  of  the  barrack-rooms  and  of  the  corridors  giving  access  to  them.  The 
rooms  are  over  the  troop  stables,  and  the  whole  place  smells  of  ammonia." 

It  would  have  been  particularly  instructive  to  know  the  mortality  among 
the  occupants  of  the  Hyde  Park  Barracks,  thus  conducted,  in  the  very  heart 
of  London  ;  but  it  does  not  appear  to  be  given  in  the  report. 

Equally  bad,  in  point  of  arrangement  of  buildings  and  over-crowding, 
were  the  Wellington  Barracks.  Of  the  seven  acres  and  over  of  ground 
pertaining  thereto,  three  are  covered  with  large  blocks  of  buildings,  con- 


1863.] 


Report  of  the  Sanitary  Commission. 


115 


taining  regulation  space  for  1530  non-commissioned  officers  and  men,  giving 
a  density  of  326,000  inhabitants  per  square  mile,  for  the  built  area,  being 
nearly  double  that  of  East  London,  which  is  one  of  the  most  densely  popu- 
lated town  districts  in  England.  The  great  defect  in  this  instance,  as  in 
many  others  named,  is  in  the  buildings  being  so  arranged,  with  regard  to 
each  other,  as  to  prevent  the  free  circulation  of  air  around,  among,  and 
through  them. 

Crowding  buildings  together,  placing  them  in  hollow  squares,  or  with 
narrow  dark  lanes  between  lofty  three  or  four-story  buildings,  without 
any  outlet  to  prevent  stagnation  of  air,  with  the  ground  rising  rapidly 
behind  them  ;  placing  the  men's  rooms  immediately  over  the  stables,  with 
the  smell  of  the  privies  constantly  pervading  the  kitchens ;  destitution  of 
sufficient  light  and  ventilation;  without  adequate  means  of  cleanliness — 
such  is  the  external  manner  of  the  buildings  in  which,  to  a  large  extent, 
the  army  of  England  has  been  kept,  according  to  the  report  of  her  own 
examiners.  The  internal  arrangements,  as  from  this  may  be  readily  sup- 
posed, are  equally  insalubrious  :  as,  for  example,  placing  barrack-rooms 
back  to  back,  with  windows  only  on  one  side,  and  no  thorough  draft;  con- 
structing barrack-rooms  over  stables;  providing  means  of  access  to  the 
rooms  by  long  internal  corridors,  or  by  corridors  covering  one  side  of  the 
rooms;  providing  accommodation  for  non-commissioned  officers  by  wooden 
bunks  inside  the  men's  rooms,  so  as  to  obstruct  light  and  ventilation ;  omit- 
ting to  provide  proper  staircases,  and  taking  space  for  stairs  out  of  the 
barrack -rooms;  using  basements  for  barracks,  &c.  &c. 

"  Errors  in  plan  and  construction,  similar  to  those  enumerated  above,  exist  to 
a  greater  or  less  degree  in  the  majority  of  the  barracks  we  have  visited,  but  they 
are  to  be  seen  in  the  most  aggravated  form  in  buildings  which  have  not  been 
originally  erected  as  barracks,  but  have  been  adapted  to  that  object." 

"Arbour  Hill  Barrack,  Dublin,  was  once  a  prison,  and,  as  such,  was  not  fit 
for  prisoners.  It  is  now  a  barrack  for  91  men.  If  it  were  proposed  to  restore 
it  to  its  former  use,  no  inspector  of  prisons  would  be  justified  in  sanctioning  it." 

Another  similar  instance  is  mentioned  of  an  old  French  prison  at  Cork, 
and  several  of  the  conversion  of  factories,  shops,  castle  halls,  combining  all 
the  evils  imaginable  as  dwellings. 

Such,  in  brief,  was  the  lamentably  unwholesome  condition  of  the  Soldiers' 
Homes  of  one  of  the  most  aristocratic  nations  of  the  earth  in  the  nineteenth 
century,  when  this  commission  probed  the  evils  to  the  bottom,  and  set 
about  the  necessary  reform.  This,  under  the  liberal  powers  granted  them, 
they  appear  to  have  done  thoroughly  and  scientifically.  Everything  that 
can  influence  the  sanitary  condition  of  the  barracks  and  hospitals  has  re- 
ceived their  minute  and  particular  attention,  even  to  the  nature  and  colour 
of  the  material  best  adapted  for  wall  and  ceilings.  In  fact,  every  hospital 
government,  and  every  architect,  may  study  the  principles  of  construction 
and  arrangement,  laid  down  in  this  volume,  with  advantage.  Never  before 
has  such  a  sanitary  work  been  carried  on  to  such  an  extent,  and  the  one 
hundred  neat  and  well  explained  figures,  illustrating  the  defective  plans  and 
those  approved  and  adopted  by  the  commission,  give  abundant  facilities  for 
the  thorough  understanding  of  the  text.  In  fact,  the  report  is  a  thorough 
exposition  of  the  true  principles  which  should  be  put  in  practice  in  military 
barracks  and  hospitals  everywhere,  and  a  chapter  on  the  "General  Sanitary 
Principles  applicable  to  the  Arrangement  and  Construction  of  Fixed 
Camps,"  is  also  given. 

To  the  subject  of  Ventilation  of  Barracks  the  commission  appear  to 


116 


Reviews. 


[Jan. 


have  given  a  large  portion  of  their  consideration,  as  its  great  importance 
demanded,  and  the  report  contains  a  very  minute  and  intelligent  account 
both  of  the  theories  adopted  and  the  plans  executed  for  the  purpose.  We 
should  like  to  give  our  readers  the  benefit  of  the  whole  of  this  part  of  the 
report  for  the  double  purpose  of  showing  that  a  familiarity  with  this  topic, 
both  in  philosophy  and  practice,  in  a  medical  man,  is  not  only  not  beneath 
his  dignity,  but  that  without  it,  he  is  but  half  prepared  for  the  discharge  of 
his  professional  duties.  We  are  able,  at  present,  however,  to  give  only  the 
following  quotations  and  descriptions.  A  discussion  of  the  methods  of 
Ventilation  by  Propulsion,  by  means  of  the  fan,  the  screw,  and  the  pump, 
is  followed  by  illustrated  descriptions  of  five  several  modifications  of  venti- 
lating apparatus  which  were  seen  in  operation  by  them — viz.,  Arnott's 
chimney  valve ;  Sherringham's  iron  air-brick,  or  box,  communicating 
directly  with  the  external  air ;  Watson's  &  Maekinn  ell's  double  current 
tubes ;  and  Muir's  square  tube,  divided  into  four  parts.  These  are  all  re- 
garded as  having  special  advantages  in  certain  cases,  chiefly  guard-rooms, 
but  they  were  found  inapplicable  to  barracks  and  hospitals,  as  not  comply- 
ing with  all  the  requisitions  of  volume,  variety  of  situation,  avoidance  of 
cold  currents,  &c. 

"  The  following  is  the  problem  requiring  to  be  solved  in  ventilating  a  bar- 
rack :  In  a  building  consisting  of  a  number  of  rooms,  generally  entered  from 
common  passages  or  staircases,  sometimes  directly  from  the  outer  air,  and  each 
having  an  open  fireplace,  ivhicfait  is  essential  in  every  instance  to  retain,  how 
to  supply  at  all  seasons  and  temperatures,  and  by  day  and  night,  each  room  by 
itself,  and  independently  of  every  other  room,  with  a  sufficiency  of  air  to  keep 
the  room  healthy,  and  at  the  same  time  to  prevent  the  temperature  from  falling 
below  what  is  required  for  the  comfort  of  the  men.  To  do  this  with  the  least 
possible  interference  with  the  structure  of  the  rooms,  on  a  plan  not  easily  de- 
ranged, and  at  a  minimum  of  cost? 

"  The  terms  of  this  problem  show  at  once  the  difficulties  in  the  way  of  venti- 
lating barracks.  None  of  the  methods  we  have  seen  in  use  afford  anything  like 
a  solution  of  it,  and  we  have  had  to  consider  the  whole  problem  anew.  We  have 
endeavoured  to  solve  it,  and  we  believe  we  have  succeeded  in  doing  so  to  an 
extent  sufficient  for  all  practical  purposes. 

"Amount  of  Fresh  Air  per  Man  required. — We  began  the  work  by  endea- 
vouring to  ascertain  approximately  the  amount  of  fresh  air  required  to  keep  a 
sleeping-room  healthy.  Various  attempts  have  been  made  at  different  times  to 
settle  this  amount  scientifically,  but  nearly  every  experimenter  has  arrived  at  a 
different  estimate  of  the  quantity. 

••  These  differences  in  opinion  have  arisen  from  not  sufficiently  considering  the 
various  offices,  already  mentioned,  which  fresh  air  has  to  perform  in  the  venti- 
lation of  human  dwellings,  and  from  not  looking  at  the  practical  rather  than  the 
scientific  side  of  the  question. 

"One  set  of  experimenters  have  based  their  calculations  on  the  quantity  of 
air  required  to  dilute  the  carbonic  acid,  produced  by  respiration,  down  to  the 
proportion  in  which  that  gas  exists  in  the  external  atmosphere.  Other  experi- 
menters have  taken  the  amount  of  air  required  to  dissolve  the  aqueous  vapour 
p$caping  from  the  skin  and  lungs,  and  to  diffuse  it  so  as  to  raise  the  hygrometric 
state  of  the  air  to  the  same  healthy  standard  as  that  of  the  outer  atmosphere. 

M  The  estimates  are  hence  very  various,  and  differ  to  the  extent  of  two,  three, 
or  four  times,  as  to  the  amount  of  air  required  for  health ;  a  difference  which 
proves  how  little  is  yet  known  scientifically  on  the  subject. 

The  practical  argument  as  to  the  amount  of  fresh  air  required  to  ventilate 
a  room  is,  in  our  opinion,  of  far  more  weight  than  the  scientific  one.  We  find, 
for  example,  that  nature  has  provided  in  the  atmosphere  unlimited  extent  and 
constant  means  of  purification  and  of  movement. 

"  The  building  of  dwellings  interferes  with  these  natural  conditions,  by  inclos- 


1863.] 


Report  of  the  Sanitary  Commission. 


in 


ing  air  in  confined  spaces,  saturating  that  air  with  impurities,  and  rendering  it 
stagnant.  It  may  be  fairly  argued,  as  indeed  has  been  proved  by  experience, 
that  those  dwellings  are  the  most  healthy  in  which  the  natural  conditions  of  the 
atmosphere  are  most  perfectly  preserved.  Chemistry  has  told  us  distinctly 
enough  that  at  least  200  cubic  feet  of  air  per  hour  is  required  by  a  human  being, 
for  the  mere  purposes  of  diluting  the  carbonic  acid  and  water  given  off  from  the 
body  to  the  same  standard  as  they  exist  in  the  atmosphere  itself.  But  chemistry 
takes  no  cognizance  of  those  aerial  poisons  eliminated  from  the  skin  and  lungs, 
and  which  in  stagnant  air  are  perfectly  cognizable  to  the  senses,  even  after  the 
air  has  been  diluted  to  the  extent  stated.  Indeed,  the  object  to*  be  served  by 
ventilation  is,  primarily,  the  dilution  and  removal  of  the  poisonous  exhalations, 
and  if  this  be  secured  the  carbonic  acid  and  water  will  be  removed  at  the  same 
time. 

"  Few  persons  are,  perhaps,  aware  that  an  ordinary  barrack  fireplace  removes 
a  much  larger  amount  of  air  than  is  required  merely  to  dilute  the  carbonic  acid 
and  water  to  a  healthy  standard.  The  quantity  varies,  of  course,  with  the  sec- 
tion, height,  and  temperature  of  the  chimney  flue,  and  also  with  the  force  and 
direction  of  the  wind. 

"  The  extremes  may  be  practically  assumed  at  from  6000  cubic  feet  per  hour 
up  to  ten  times  that  amount.  A  twelve-men  room,  affording  500  cubic  feet  per 
man,  would,  on  the  lowest  estimate,  have  500  cubic  feet  of  air  per  man  per  hour 
supplied  to  it  by  the  chimney  draft  alone ;  that  is  to  say,  the  fire  grate  will 
insure  a  ventilation  above  twice  as  great  as  will  fulfil  the  requirements  of  chem- 
istry ;  and  yet  it  has  been  ascertained  by  sufficient  experience  that  rooms  so 
ventilated  are  both  offensive  and  unwholesome. 

"  The  result  is,  no  doubt,  partly  attributable  to  the  point  of  the  room  from 
which  the  foul  air  is  drawn;  for,  although  carbonic  acid,  like  every  other  gas, 
diffuses  itself  equally  through  the  cubic  contents  of  a  room,  those  poisonous, 
organic  compounds,  to  which  we  have  referred,  are  detected  by  the  senses  most 
strongly  near  the  ceilings  of  apartments,  as,  for  instance,  in  the  galleries  of  un- 
ventilated  churches,  theatres,  &c. ;  so  that  in  all  rooms  ventilated  only  by  the 
fireplaces,  there  is  a  reservoir  of  foul  air  situated  above  the  range  of  its  venti- 
lating power.  The  fireplace  may  be  made  an  admirable  adjunct  to  ventilation, 
but  by  itself  it  is  certainly  not  sufficient  for  the  purpose. 

"The  sense  of  smell  affording  the  chief  indication  of  the  healthiness  or  un- 
healthiness  of  a  room  atmosphere,  and  differing  as  the  delicacy  of  this  sense  does 
in  different  individuals,  it  is  not,  perhaps,  possible  to  arrive  at  an  absolute 
standard  of  ventilation ;  but  in  order  to  obtain  some  practical  estimate  of  the 
quantity  of  air  required  to  preserve  the  air  of  a  barrack-room  sufficiently  pure, 
and  of  the  size  of  shafts  and  inlets  required  to  insure  this  amount,  we  had  air- 
shafts  having  certain  definite  sections  carried  from  the  corners  of  the  ceilings  of 
twelve  barrack-rooms,  in  the  Wellington  Barracks,  up  through  the  roof,  so 
arranged  that  the  apertures  might  be  contracted,  and  the  quantity  of  air  passing 
up  each  shaft  measured  by  a  delicate  anemometer  constructed  by  Naumann,  of. 
Paris,  for  the  express  object. 

"  The  measurements  were  taken  at  different  periods,  during  several  months, 
between  two  and  five  o'clock  in  the  morning.  The  requisite  observations  of 
temperature  without  and  within  the  rooms,  and  of  the  hygrometric  state  of  the 
air,  were  also  taken,  and  the  sensible  state  of  the  room  atmosphere  was  observed 
at  the  same  time. 

"  From  these  observations,  as  well  as  from  others  which  we  have  been  enabled 
to  make,  we  are  of  opinion  that  an  estimate  on  which  we  based  our  first  im- 
provements in  ventilation,  is  sufficiently  near  the  truth  for  practical  purposes. 
It  is  as  follows  :  That  in  a  barrac*k-room  containing  a  number  of  men,  at  600 
cubic  feet  per  man,  the  whole  air  of  the  room  should  be  renewed  at  least  twice  in 
the  hour.  In  other  words,  that  each  man  should  have  in  round  numbers  1200 
cubic  feet  of  fresh  air  supplied  to  him  per  hour.  Even  this  amount  may  not  be 
sufficient  to  preserve  a  barrack-room  entirely  free  of  odour  at  all  times  and  sea- 
sons ;  but  the  difficulties  of  a  thorough  solution  of  a  problem  where  the  condi- 
tions are  so  variable,  have  led  us  to  adopt  this  as  our  unit  of  ventilation,  while 
in  the  ventilating  plans  we  have  carried  out,  it  is  always  possible  to  increase  the 


118 


Reviews. 


[Jan. 


amount  without  difficulty.  After  our  plans  had  been  some  time  in  operation, 
we  were  glad  to  learn,  from  a  report  on  the  warming  and  ventilation  of  dwellings, 
made  to  the  General  Board  of  Health  by  Messrs.  Fairbairn,  Glaisher  and  Wheat- 
stone,  that  a  similar  unit,  namely,  from  15  to  20  cubic  feet  per  man  per  minute, 
had  been  arrived  at  by  these  gentlemen.  But  while  adopting  this  unit,  we  hold 
it  at  the  same  time  to  be  an  indispensable  condition,  that  each  man  should  have 
the  amount  of  space,  600  cubic  feet,  recommended  by  the  Royal  Commission." 

"  Principle  of  Ventilating  Barrack  Rooms. — The  next  point  is  to  determine 
what  should  be  the  principle  of  ventilation  adopted.  We  have  decided,  after 
a  careful  consideration  of  the  different  methods  which  have  been  in  use,  to  keep 
each  barrack  room  independent  of  every  other  in  respect  to  ventilation,  and  to 
depend  for  the  movement  of  the  air  in  barrack  rooms  upon  the  fire-place  and 
upon  the  element  of  the  difference  of  temperature  between  the  air  outside  and 
the  air  within.  According  to  the  law  of  dilatation  discovered  by  Dalton  and 
Gay  Lussac,  atmospheric  air,  in  the  process  of  being  heated  from  the  freezing  to 
the  boiling  point  of  water,  increases  in  volume  0.375,  or  about  f  of  its  original 
bulk,  which  gives  a  dilatation  of  a  little  more  than  0.002  for  every  degree  of 
Fahrenheit.  If  the  air  inside  a  room  were  20°  Fahr.  warmer  than  the  outside, 
the  air  in  the  room  would  be  expanded  to  a  twenty-fifth  part  more  in  bulk,  and 
would  be  to  that  extent  specifically  lighter  than  the  outside  air.  The  colder 
air  outside  has  thus  a  tendency  to  press  upwards  the  warmer,  expanded  and 
lighter  air  within  the  barrack  room,  for  which  at  present  there  is  no  outlet." 

In  accordance  with  the  law  here  enunciated,  each  room  was  provided 
with  a  shaft  whose  sectional  area  was  adjusted  to  its  length  and  the  num- 
ber of  inmates  of  the  room.  A  more  proper  rule  governing  the  dimensions 
of  the  shaft,  would  be  the  cubic  space  of  the  room  ;  but  this  would  answer 
only  in  cases  in  which  the  number  of  occupants  would  conform  to  the  cubic 
area — a  circumstance  which  was  hoped  for  in  the  future. 

In  rooms  on  the  top  floor,  shafts  were  recommended  of  a  sectional  area 
of  one  inch  to  every  fifty  cubic  feet  of  room  space  ;  for  floors  next  below 
the  upper,  one  inch  to  every  fifty -five  feet,  and  in  barracks  of  three  floors, 
an  area  of  one  inch  to  sixty  feet  was  required  for  the  lowest.  The  velocity 
of  the  air  in  the  shaft,  and  hence  its  ventilating  power,  will  depend,  1st,  on 
the  difference  of  temperature  between  the  inner  and  outer  air;  2d,  on  the 
length  of  the  shaft ;  3d,  on  the  amount  of  friction  in  the  shaft ;  and,  4th, 
on  the  freedom,  or  otherwise,  with  which  the  air  to  supply  the  shaft  enters 
the  room. 

In  giving  these  as  the  elements  which  alone  govern  the  velocity,  and 
consequently  the  quantity,  of  the  air  passing  through  such  shafts,  the  com- 
missioners have  omitted  the  mention  of  another  which  has  as  much,  if  not 
more,  influence  over  the  result  as  any  other,  and  that  is  the  shape  of  the 
shaft. 

It  will  be  readily  admitted  that  the  current  of  air  through  a  shaft  whose 
upper,  or  discharging  extremity,  is  contracted  to  a  smaller  area  than  its 
lower,  or  receiving  extremity,  must  necessarily  be  more  or  less  impeded  from 
the  double  cause  of  increased  friction  of  the  air  in  the  tube,  and  the  crowd- 
ing of  it  at  the  point  of  discharge.  In  a  shaft  of  parallel  sides,  i.  e.,  of 
equal  calibre  through  its  whole  length,  there  will  be  some  friction,  but  no 
crowding  at  the  point  of  exit,  unless  it  should  happen  that  by  any  means 
the  air  should  become  raised  in  temperature  as  it  passes  through,  and  by 
its  consequent  increased  expansion  it  should  press  against  the  sides  of  the 
shaft.  All  of  these  obstructions,  however,  are  entirely  overcome,  and  the 
through  passage  of  the  air  facilitated,  by  a  slight  gradual  enlargement  of 
the  area  of  the  shaft  as  it  advances  in  length.  By  this  gradual  enlarge- 
ment, the  shaft  obtains  the  shape  of  a  trumpet,  and  the  column  of  air 


1863.] 


Report  of  the  Sanitary  Commission. 


119 


within  it,  if  set  in  motion  by  any  means,  will  find  more  and  more  room  as 
it  ascends,  and  it  will  consequently  expand  to  fill  the  partial  void,  or  at 
least  will  not  infringe  upon  the  wider  sides  of  the  tube,  and  thus  avoid  the 
impediment  of  friction,  at  the  same  time  the  partial  vacuum  invites  a  more 
rapid  inflow  below.  The  form  here  alluded  to  has  been  successfully  adopted 
in  factory  chimneys,  where  a  powerful  draft  is  required ;  and  has  also  been 
very  successfully  applied  to  ventilating  purposes. 

Care  must  be  taken,  however,  not  to  increase  the  calibre  of  the  shaft  too 
rapidly,  in  other  words  to  make  the  egress  of  air  in  too  great  dispropor- 
tion to  its  ingress;  otherwise,  the  action  of  the  shaft  will  be  counteracted 
by  opposing  currents  at  the  outer  end.  The  proportion  of  increase  in  size 
has  been  in  practice,  in  those  cases  which  have  fallen  under  our  observation, 
limited  to  one  inch  increased  diameter  of  a  circular  shaft  for  every  twelve 
inches  in  length.  Within  this  limit  the  action  is  found  to  be  greatly  in- 
creased, while  beyond  it,  counteracting  currents  seem  to  be  produced  in 
greater  or  less  degree. 

Although  the  application  of  this  principle  of  the  expanding  tube  appears 
to  have  been  but  recently  applied  to  chimneys  and  ventilating  shafts,  it  is 
nevertheless  as  old  as  the  circulation  of  the  blood.  John  Hunter  took 
great  pains  to  prove  that  the  aorta  had  its  diameter  enlarged  as  it  pro- 
ceeded from  the  heart,  and  that  the  areas  of  the  branches  of  an  artery  were 
greater  than  the  diameter  of  the  parent  trunk.  This  principle  in  the  flow- 
ing of  liquids,  whereby  the  friction  of  the  fluids  against  the  sides  of  the 
containing  tubes  is  avoided,  is  just  as  applicable  to  currents  of  gaseous 
fluids,  and,  as  we  have  several  times  seen  demonstrated,  is  a  highly  valu- 
able aid  in  ventilation  of  buildings.  With  the  addition  of  the  conical  form 
to  the  ventilating  shafts  of  the  British  barracks,  the  commissioners  would 
doubtless  have  perfected  their  arrangements. 

But,  as  correctly  stated  by  the  commissioners — 

"  A  ventilating  shaft  and  a  chimney-flue  are  not  of  themselves  sufficient  to 
ventilate  a  room.  If  a  room  has  two  fire-places,  they  will  draw  against  each 
other,  and  the  fire-place  with  the  strongest  draught  will  supply  itself  by  drawing 
the  smoke  down  the  other  chimney,  unless  it  can  obtain  an  air-supply  with  a 
smaller  expenditure  of  force.  For  a  similar  reason,  if  a  closed  barrack  has  no 
other  means  of  ventilation  than  a  foul  air-shaft  and  a  chimney  flue,  the  fire-place 
will  certainly  supply  itself  by  drawing  air  down  the  shaft,  and  troublesome  down 
drafts  will  be  produced.  It  is  essential,  therefore,  to  provide  inlets  for  air  to 
supply  both  the  fire  and  the  ventilating  shaft." 

It  was  determined,  on  this  reasoning,  to  furnish  each  barrack  room 
needing  them,  with  "  inlets  for  fresh  air,"  and  further,  it  was  decided  to 
place  them  close  to  the  ceiling,  to  afford  opportunity  for  the  air  to  be  dis- 
seminated as  widely  as  possible  over  the  room,  before  being  drawn  away 
by  the  fire,  or  the  foul  air  shaft.  In  barrack  rooms  of  ordinary  size,  two 
inlets  were  recommended  on  opposite  sides  of  the  room,  a  greater  number 
for  larger  rooms.  These  inlets  were  made  of  iron  or  perforated  air  bricks ; 
to  prevent  unpleasant  draughts,  a  triangular  wooden  box  covered  the  inside 
opening,  which  received  the  air  at  the  cornice,  and  a  perforated  zinc  plate 
which  formed  the  upper  side  of  the  box,  distributed  the  air  in  an  upward 
direction,  and  as  it  struck  the  ceiling  it  was  diffused  over  the  room.  Inlets 
near  the  floor  were  discarded,  for  the  double  reason  that  the  soldiers  would 
close  them,  and  the  current  through  them  would  not  mingle  freely  with  the 
air  of  the  room,  but  pass  more  directly  to  the  grate  and  be  drawn  up  the 
chimney. 


120 


Reviews. 


[Jan. 


"  Ventilation  of  Stables  wider  Barrack  Rooms. — In  every  cavalry  barrack, 
having  men's  rooms  over  stables,  we  have  endeavoured  as  far  as  possible  to  di- 
minish the  risk  of  effluvia  passing  into  the  men's  rooms  through  the  stable  build- 
ings, by  carrying  up  four  shafts  one  from  each  corner  of  the  stable,  to  above  the 
roof.  These  shafts  have  a  total  conjoint  area  of  twelve  square  inches  per  horse. 
Their  object  is  twofold  :  to  improve  the  ventilation  of  the  stable  itself,  and  to 
prevent  the  accumulation  of  foul  air  at  the  ceiling  of  the  stable.  Where  it  has 
been  necessary  to  carry  these  shafts  through  the  men's  rooms,  they  have  been 
lined  inside  with  soldered  zinc,  in  order  to  obviate  any  risk  of  leakage  within  the 
room.  "We  have  found  ventilation  by  four  shafts,  one  carried  up  from  each 
corner,  with  inlets  for  fresh  air,  similar  to  those  for  barrack  rooms,  but  without 
the  covers,  by  far  the  most  satisfactory  method  for  stables  with  rooms  of  any 
kind  over  them.  For  stables  without  rooms  over  them,  a  raised  ridge  forms  the 
best  outlet,  with  a  row  of  perforated  bricks  under  the  eaves  to  act  as  inlets  for 
fresh  air." 

Thus  were  the  means  for  maintaining  a  pure  atmosphere  varied  by  the 
commissioners  to  suit  the  circumstances  of  each  room,  or  building,  accord- 
ing to  its  size,  its  position,  its  uses,  &c.  In  some  instances  Arnott's  silk- 
flap  valve,  in  others  Muir's  or  Mackinnell's  double  current  ventilator, 
or  perforated  glass  panes  in  the  windows,  or  Sherringham's  ventilator  (an 
iron  air  brick,  or  box,  inserted  close  to  the  ceiling,  and  affording  a  direct 
communication  with  the  external  air)  was  employed,  and  thus  did  they 
indefatigably  regulate  the  atmospheric  condition  of  every  room  of  every 
kind  in  all  the  barracks  and  hospitals  of  the  United  Kingdom.  The  ven- 
tilation of  gas  burners  also  came  within  their  observation,  and  was  effected 
by  a  funnel  over  the  jet,  conducting  the  air  from  it  to  the  chimney  or  a 
ventilating  shaft. 

In  addition  to  the  ventilation  of  these  important  institutions,  every  other 
matter  connected  with  their  sanitary  condition  came  under  the  observation 
and  correction  of  the  commissioners,  and  the  results  of  their  labours  is  a 
monument  to  their  fidelity  and  intelligence,  an  example  to  all  the  world. 

Improvements  in  warming  and  lighting ;  in  water  supply ;  in  drainage, 
latrines,  and  urinals  (of  which  copious  pictorial  illustrations  are  given),  in 
ash  and  manure  pits;  in  ablution  rooms  and  baths  (Stirling  Castle  is  the 
only  barrack  in  which  a  drinking  fountain  in  use  was  found  in  all  Great 
Britain);  in  cook-houses  and  cooking  apparatus ;  in  wash-houses  and  dry- 
ing closets — all  were  undertaken  and  accomplished  in  the  most  thorough 
manner  possible. 

The  amount  of  labour  performed  by  the  commissioners  may  be  inferred  by 
the  fact  which  we  gather  from  the  appendix  to  the  report,  that  out  of  the 
164  barracks  inspected  and  "doctored"  by  them,  there  were  only  five  in 
which  the  regulation  number  of  inmates  did  not  exceed  the  allowance  of 
one  man  to  each  600  cubic  feet  of  air,  the  excess  varying  from  9  (the  bar- 
racks of  the  Royal  Engineers  at  Portsmouth)  to  1364  (at  Chatham).  So 
also  with  regard  to  the  114  military  hospitals  examined;  there  were  but  6 
in  which  1200  cubic  feet  of  air  were  allowed  to  each  bed,  a  great  majority 
having  less  than  700,  and  a  large  number  less  than  500. 

In  the  construction  of  hospitals,  the  great  points  to  be  secured  are : — 

1.  Purity  of  external  atmosphere.  ' 

2.  Abundance  of  pure  air  and  sunlight  within  the  building. 

3.  Facility  of  administration  and  discipline. 

Acting  on  these  principles,  the  report  proceeds  with  a  thorough  digest  of 
the  particulars  to  be  observed  in  the  selection  of  proper  sites,  with  a  notice 
of  such  external  evils  as  should  be  avoided ;  the  isolation  of  hospitals ; 


1863.] 


The  New  Sydenham  Society. 


121 


the  test  of  healthiness  of  sites;  the  plan  and  construction  of  the  buildings  ; 
the  position  of  the  beds  ;  the  size  and  number  of  windows ;  arrangement 
of  wards  and  ward  offices,  and  administrative  offices  ;  the  number  of  sick 
under  one  roof,  and  all  with  reference  to  the  three  recognized  varieties  of 
hospitals,  viz.: — 

1.  The  Regimental  Hospital,  single  or  consolidated. 

2.  General  hospitals. 

3.  Camp,  or  temporary  hospitals. 

Several  plans  for  each  of  these  varieties  are  given,  to  which  no  descrip- 
tion unaccompanied  with  the  engraved  designs  can  do  justice,  or  render 
comprehensible.  As  the  latest,  and  doubtless  the  best  authority  on  the 
various  topics  discussed,  this  volume  is  peculiarly  valuable  to  us  at  the 
present  time,  and  from  personal  observation  of  several  of  the  general  mili- 
tary hospitals  erected  since  the  commencement  of  the  rebellion,  we  know 
its  pages  might  have  been  consulted  with  great  advantage  to  their  plans 
of  construction  and  arrangement,  which,  it  is  evident  from  their  defects,  has 
not  been  the  case.  In  too  many  instances,  the  proposition  laid  down  by 
the  commissioners,  as  the  great  object  sought  in  the  construction  of  a  hos- 
pital, to  which  everything  else  is  only  subsidiary,  has  been  overlooked  on 
this  as  well  as  on  the  other  side  of  the  Atlantic,  viz. :  the  recovery  of  the 
largest  number  of  sick  men  in  the  shortest  possible  time. 

On  the  subject  of  the  ventilation  of  tents,  which  the  commissioners  justly 
regard  as  one  of  the  most  important  necessities  of  camp  life,  and  the  neglect 
of  which  is  a  prolific  source  of  disease,  they  give  some  good  advice,  though 
we  should  have  been  glad  to  see  a  more  elaborate  discussion  of  that  point. 
They  are  content  with  simply  recommending  "  ventilating  openings  of  suffi- 
cient size  around  the  tent  pole."  In  this  connection  we  are  pleased  to  be 
able  to  say  that  to  our  own  country  belongs  the  credit  of  being  the  first  to 
use  a  well  ventilated  tent,  and  one  that  combines  with  this  improvement 
another  highly  important  one,  viz. :  arrangement  by  which  the  men  are 
raised  above  the  ground  when  asleep,  thus  avoiding  the  evils  incident  to 
contact  with  the  cold  wet  soil.  This  is  accomplished  by  an  ingeniously 
devised  system  of  hammocks,  which  are  stretched  in  a  very  simple  and  se- 
cure manner  on  the  wooden  bars  forming  the  frame-work  of  the  tent,  and 
which,  when  removed  in  the  day  time,  leave  a  free  space  of  the  whole  interior 
of  the  tent — a  great  advantage  over  all  other  forms  of  beds,  which  neces- 
sarily occupy  the  floor  during  the  day  as  well  as  night.  We  regret  that  this 
tent  has  not  been  more  generally  introduced  into  the  army.      J.  H.  G. 


Art.  XVIII.— The  New  Sydenham  Society.  Yol.  XL  Selected  Mono- 
graphs: Czermak  on  the  Practical  Uses  of  the  Laryngoscope ;  Dusch 
on  Thrombosis  of  the  Cerebral  Sinuses;  Schroeder  Van  der  Kolk  on 
Atrophy  of  the  Brain;  Radicke  on  the  Application  of  Statistics  to 
Medical  Inquiries;  and  Esmarch  on  the  Uses  of  Cold  in  Surgical 
Practice.    London,  1861.    8vo.  pp.  329. 

Czermak's  brochure  was  originally  published  in  the  German  language, 
at  Leipzig,  in  1860,  under  the  title  of  Der  Kehlkopfspiegel  und  seine  Ver- 


122 


Reviews. 


[Jan. 


wertkung  fur  Physiologie  und  Medizin.  In  June  of  the  same  year,  a 
French  translation  appeared  in  Paris  from  the  pen  of  Dr.  L.  Mandl.  Of 
this  French  edition,  a  literal  English  translation  has  been  executed  for  the 
Sydenham  Society  by  Dr.  G.  D.  Gibb,  with  the  sanction  of  the  author,  who 
has  enlarged  the  work  by  the  addition  of  an  appendix  on  Rhinoscopy,  to- 
gether with  some  notes  and  sketches. 

This  monograph  is  the  second  edition,  as  the  author  calls  it,  of  all  the 
articles  published  by  him  in  various  medical  journals  in  1858  and  1859,  in 
which  he  has  made  it  his  study  to  bring  into  scientific  and  practical  use  the 
manifold  applications  of  the  principle  of  Liston  and  Garcia's  method  of 
inspecting  the  larynx. 

The  Sydenham  Society  has  acted  very  judiciously  in  giving  to  this  essay 
an  English  dress,  inasmuch  as  the  persevering  and  well-directed  investiga- 
tions recorded  therein  have  been  especially  useful  in  bringing  about  a  recog- 
nition of  laryngoscopy  as  a  most  valuable  aid,  on  the  one  hand,  to  the 
physiologist  in  reference  to  the  mechanism  of  phonation,  and,  on  the  other, 
to  the  practical  physician  in  regard  to  the  diagnosis  and  nature  of  various 
pathological  conditions  of  the  laryngeal  apparatus.  The  passing  hint  em- 
bodied in  a  few  lines  of  one  of  the  paragraphs  of  Liston's  Practical  Sur- 
gery, and  the  more  definite  mechanical  suggestions  of  Avery  and  Garcia, 
have  been  so  brilliantly  realized  in  the  labours  of  Professor  Czermak  that 
his  monograph  upon  the  subject  will  always  occupy  an  important  place  in 
the  literature  of  this  branch  of  medical  research — a  literature  which  we  may 
say,  en  passant,  has  already  been  enriched  during  the  last  three  years  by 
contributions  from  Turck,  Gerhardt,  Battaille,  Merkel,  Sieveking,  and  other 
well-known  observers. 

A  case  of  formation  of  a  thrombus  in  the  superior  longitudinal  sinus, 
which  fell  under  the  notice  of  Prof.  Th.  von  Dusch,  of  the  University  of 
Heidelberg,  led  to  the  publication  of  the  interesting  paper  on  Thrombosis 
contained  in  the  volume  under  notice. 

The  formation  of  thrombi  in  the  venous  system  during  life  is  a  subject  of 
much  pathological  interest.  Although  cases  of  this  affection  have  been 
recognized  in  various  writings  since  the  days  of  Morgagni,  the  conditions 
under  which  they  most  frequently  occur,  and  the  effects  of  their  formation, 
have  not  been  clearly  understood  until  quite  recently.  By  Hunter,  they 
were  considered  to  be  exudations  upon  the  inner  surface  of  inflamed  veins. 
They  were  afterwards  shown  to  be  true  coagula,  and  were  supposed  to  be 
the  result  of  phlebitis — a  view  to  which  Cruveilhier  gave  the  sanction  of 
his  authority.  The  investigations  of  Virchow  have  shown,  however,  that 
phlebitis  is  seldom  followed  by  coagulation  of  the  blood  in  the  inflamed 
veins,  and  that,  on  the  contrary,  in  the  large  number  of  cases,  the  forma- 
tion of  coagula  in  the  veins  precedes  the  inflammation  in  them.  Dr.  Dusch 
has  collected  and  critically  analyzed  quite  a  large  number  of  cases  of  thrombi 
occurring  in  the  cerebral  sinuses  from  various  causes.  From  his  investi- 
gations, he  draws  the  following  conclusions  : — 

"  Thrombosis  of  the  sinuses  of  the  brain  is  either  a  prolongation  from  the 
neighbouring  veins,  or  it  originates  primarily  in  the  sinus. 

"  A.  Thrombosis  of  the  sinuses  by  prolongation  is  the  consequence — 

"  I.  Of  'processes  of  inflammation  tending  to  necrosis  and  sanies  in  the  vas- 
cular precincts  of  the  sinus. 

"These  consist  chiefly  in  caries  of  the  bones  of  the  skull,  caries  of  the  petrous 
bone  from  internal  otitis  being  most  frequent. 


1863.] 


The  New  Sydenham  Society. 


123 


"  IT.  Of  injuries  of  the  bones  of  the  skull,  inasmuch  as  the  hemorrhage  from 
the  diploe  which  follows  them  leads  to  coagulation  (hemorrhagic  thrombosis). 

"III.  Of  effusions  of  Mood  into  the  substance  of  the  brain  or  its  membranes, 
from  which  the  thrombus  extends  through  the  smaller  veins  into  the  sinuses 
(hemorrhagic  thrombosis). 

"  This  form  of  thrombosis  is  characterized  by  the  situation  of  the  thrombus 
in  the  sinus  (generally  azygous)  nearest  to  the  cause;  by  the  more  advanced 
softening  of  the  thrombus  ;  by  changes  in  the  walls  of  the  sinus  ;  by  inflammation 
in  the  brain  and  its  membranes ;  and  by  metastatic  processes  in  other  organs. 

"B.  Thrombosis  originating  primarily  in  the  sinus  is  the  consequence — 

"  I.  Of  influences  which  retard  the  current  of  the  blood. 

"In  the  generality  of  cases,  several  causes  act  simultaneously  in  this  direc- 
tion, partly  of  a  general,  partly  of  a  local  character. 

"i.  General  causes  retarding  the  current  of  the  blood  are — 

"a.  Deficient  energy  of  the  heart's  action. 

"a.  In  advanced  age  [marasmus  senilis).  Diminished  elasticity  of  the 
coats  of  the  arteries  must  here  be  taken  into  account  as  a  favouring 
element. 

11  (5.  In  infancy  (marasmus  infantilis). 

"y.  In  consequence  of  precedent  acute  or  chronic  diseases. 
"  b.  Diminution  of  the  quantity  of  the  blood.    Its  effect  in  retarding  the 
circulation  manifests  itself  chiefly  in  the  sinuses  of  the  brain.    (It  is  generally 
associated  with  the  causes  mentioned  under  a.) 

"a.  Direct  retardation  from  losses  of  blood. 

"j3.  Indirect  retardation  from  profuse  secretions,  in  which  cases  a  certain 
allowance  must  be  made  for  the  inspissation  of  the  blood  (diarrhoea 
and  cholera  infantum,  profuse  suppuration). 

"  c.  Impediments  to  the  expansion  of  the  lungs,  which  prevent  the  right  side 
of  the  heart  from  emptying  itself  properly.  These  impediments  exist  partly 
in  the  lungs  themselves  (pneumonia,  atelectasis,  tuberculosis),  partly  in  the 
pleura  (pleuritic  effusion),  or  result  from  deficient  action  of  the  respiratory  mus- 
cles (in  rickets,  ascites,  peritonitis).  Alone  they  do  not  appear  to  produce  a 
thrombosis  in  the  sinuses,  but  they  must  be  regarded  as  very  powerful  auxiliaries. 

"  The  thrombosis  which  results  from  the  causes  mentioned  under  B,  I,  i,  acting 
for  the  most  part  in  combination  (thrombosis  from  marasmus),  is  characterized 
by  the  situation  of  the  thrombus  most  frequently  in  one  of  the  azygous  sinuses 
(the  superior  longitudinal  or  straight  sinus);  by  its  firmness  ;  by  the  non-exist- 
ence of  disease  in  the  walls  of  the  sinus ;  by  consecutive  hemorrhages  in  the 
brain  and  its  membranes ;  and  by  the  absence  or  very  unfrequent  occurrence  of 
metastatic  processes  in  other  organs. 

"  2.  Local  causes  which  retard  the  circulation  in  the  sinuses  are — 

"  a.  Pressure  upon  the  sinus  itself  by  tumours  and  enlarged  Pacchionian 
glands. 

"6.  Pressure  upon  the  large  veins  of  the  neck  by  tumours,  in  consequence  of 
which  coagulation  occurs  first  in  them,  and,  by  extension  of  the  thrombus,  also 
in  the  sinuses. 

"  (This  comes,  properly  speaking,  under  A.) 

"c.  Intrusion  of  foreign  bodies  and  tumours  into  the  sinus,  which  diminish 
its  calibre  ;  here  contact  of  the  blood  with  the  foreign  body  must  be  taken  into 
account  as  favouring  coagulation. 

" II.  Of  diseases  of  the  wcdls  of  the  sinus,  from  altered  molecular  attraction 
between  the  diseased  walls  and  the  blood,  especially  in  inflammatory  processes 
in  the  former  (?)" 

In  1844,  the  late  Professor  Schroeder  Yan  der  Kolk  received  from  Am- 
sterdam the  body  of  an  idiotic  girl  to  be  used  at  his  anatomical  lectures. 
He  opened  the  skull  with  care,  and  found  that  the  left  half  of  the  brain  was 
softened,  atrophied,  and  in  a  state  of  morbid  degeneration.  This  patho- 
logical condition  of  the  encephalon  was  accompanied  with  atrophy  of  the 


124 


Reviews. 


[Jan. 


right  side  of  the  body.  As,  in  the  few  instances  of  this  condition  to  be 
found  in  the  works  of  modern  writers,  the  examinations  made  have  been  too 
superficial,  and  the  details  of  the  differences  between  the  healthy  and  mor- 
bidly affected  parts  have  not  been  traced  with  sufficient  accuracy,  Prof.  Yan 
der  Kolk  was  led  to  make  a  very  thorough  and  accurate  investigation  of 
the  evident  influence  of  the  cerebral  lesion  over  the  rest  of  the  system. 

By  the  philosophical  anatomist,  who  studies  structure  always  with  refer- 
ence to  fuuction,  whether  normal  or  perverted,  this  monograph  will  be  read 
with  deep  interest.  It  is  deserving  of  attentive  perusal,  not  only  because  it 
contains  the  minute  details  of  a  very  remarkable  case  of  disease,  but  also 
because  it  is  accompanied  with  copious,  critical,  and  erudite  references  to 
the  investigations  of  many  anatomical,  physiological,  and  pathological 
writers  of  eminence.  To  the  zealous  student,  the  value  of  such  references  is 
inestimable. 

Four  lithographic  plates  of  the  thickened  skull  and  atrophied  brain  ac- 
company this  paper. 

The  next  article  is  from  the  pen  of  Professor  Radicke,  of  Bonn,  and  is 
entitled:  "On  the  Importance  and  Value  of  Arithmetic  Means;  with  espe- 
cial reference  to  recent  Physiological  Researches  on  the  Determination  of 
the  Influence  of  certain  Agencies  upon  the  Metamorphosis  of  Tissue;  with 
rules  for  accurately  estimating  the  same."  This  is  an  important  contribu- 
tion to  the  logic  of  medicine. 

"At  a  time  so  prolific  in  research  of  all  kinds  as  the  present,"  writes  Dr. 
Bond,  the  translator  of  this  monograph,  "  and  when  the  aid  of  numerical  com- 
parison is  so  frequently  invoked,  not  only  in  the  domain  of  physiology  and 
therapeutics,  but  also  in  that  of  practical  medicine,  it  is  imperatively  requisite 
that  we  should  know  exactly  the  nature  and  amount  of  the  assistance  which 
such  an  aid  is  capable  of  affording.  If  it  were  necessary  to  add  to  the  illustra- 
tions which  Professor  Radicke  has  given  in  the  first  of  his  papers  of  important 
generalizations  founded  upon  an  utterly  insufficient  and  often  inaccurate  basis, 
there  would  be  little  difficulty  in  finding  them  in  the  English  medical  literature 
of  the  last  few  years.  The  service,  therefore,  which  Professor  Radicke  has  done 
to  the  cause  of  science,  in  thus  calling  attention  to  a  growing  evil,  as  well  as  in 
pointing  out  its  remedy,  can  hardly  be  over-estimated,  and  his  able  and  ex- 
haustive discussion  of  the  subject  will,  it  is  to  be  hoped,  do  something,  in  his 
own  words,  ■  to  stem  the  stream  of  baseless  and,  to  a  great  extent,  erroneous 
doctrines  by  which  medical  science  threatens  to  be  overwhelmed.'  Statistics 
are  a  most  effective  instrument  of  research  when  rightly  used ;  but,  like  other 
edged  tools,  in  unskilful  hands  they  are  as  likely  to  do  hurt  as  good." 

Radicke's  paper  is  followed  by  a  short  supplement,  written  by  Prof.  Carl 
Vierordt,  of  Tiibingen ;  and  this,  again,  by  "A  Reply  to  Prof.  Radicke's 
paper,"  published  by  Dr.  F.  W.  Ben  eke,  of  Marburg.  The  criticisms  con- 
tained in  this  "Reply"  are  noticed  by  Radicke  in  another  communication 
"On  the  Deduction  of  Physiological  and  Pharmaco-Dynamical  Probabili- 
ties from  co-ordinated  Series  of  Observations." 

In  the  last  of  these  "selected  monographs,"  Prof.  Esmarch,  of  the  Uni- 
versity of  Kiel,  advocates  most  strongly  the  employment  of  cold  in  various 
surgical  affections,  and  gives  a  detailed  account  of  its  beneficial  effects  in 
cases  of  compound  fractures,  gun-shot  fracture  of  the  tibia,  fracture  of  the 
lower  part  of  the  humerus,  traumatic  inflammation  of  the  knee-joint  after 
a  perforating  wound  of  the  joint,  suppuration  of  the  knee-joint,  inflamma- 
tion of  the  sacro-iliac  synchondrosis,  chronic  purulent  inflammation  of  the 


1863.] 


Guy's  Hospital  Reports. 


125 


knee-joint,  inflammation  of  the  cervical  vertebra?,  Pott's  curvature  formed 
by  suppuration  of  the  eighth  and  ninth  dorsal  vertebras,  chronic  rheumatic 
inflammation  of  several  dorsal  and  lumbar  vertebrae,  hot  abscess  over  the 
scapula  after  contusion,  inflammation  of  the  bursa  patellae,  contusion  of  the 
globe  of  the  eye,  destruction  of  the  eye  by  small  shot,  &c. 

In  this  communication,  the  reader  will  find  many  useful  hints  as  to  the 
best  methods  of  applying  cold,  the  extent  to  which  it  should  be  used,  and 
the  indications  for  its  employment.  J.  A.  M. 


Art.  XIX. — Guifs  Hospital  Reports.  Edited  by  Samuel  Wilks,  M.  D., 
and  Alfred  Poland.  Third  Series,  Yol.  Till.  London :  John 
Churchill,  1862.    8vo.  pp.  325. 

The  present  volume  of  this  valuable  publication  contains  twenty  original 
communications,  nine  lithographic  plates,  and  a  number  of  wood-cuts.  As 
has  been  for  some  time  past  our  practice,  we  shall  lay  before  our  readers  a 
full  analysis  of  its  contents  : — 

I.  On  Disease  of  the  Supra-Renal  Capsules;  or  Morbus  Addisonii. 
By  Samuel  Wilks,  M.  D. 

About  five  years  since  the  attention  of  the  profession  was  called  by  the 
publication  of  Dr.  Addison's  treatise  on  the  constitutional  and  local  effects 
of  disease  of  the  supra-renal  capsules,  to  a  peculiar  affection  having  as 
its  important  features  a  disease  of  those  organs,  a  discoloration  of  the 
skin,  and  a  remarkable  progressive  feebleness  of  the  patient  without  any 
apparent  cause.  The  facts  and  arguments  that  have  been  observed  and 
published  since  that  time,  in  regard  to  the  existence  or  non-existence  of  this 
affection,  the  most  important  of  which  have  been  given  in  the  quarterly 
summaries  of  the  improvements  and  discoveries  in  the  medical  sciences  in 
this  journal,  have  led  most  physicians  to  disbelieve  the  correctness  of  the 
views  of  Dr.  Addison.  It  has  unquestionably  been  shown  that  supra-renal 
disease  has  been  found  on  post-mortem  examinations  where  there  was  no 
discoloration  of  the  skin,  and  also  that  pigmentary  discoloration  constantly 
occurs  without  any  morbid  affection  of  these  organs.  It  is  known,  also, 
that  in  the  lower  animals,  when  the  capsules  have  been  extirpated  without 
great  injury  to  the  solar  plexus,  the  animal  continues  to  live  as  before ; 
and  that  in  men  disease  of  the  capsules  has  been  found  accidentally,  that  is, 
when  there  was  no  suspicion  of  disease,  no  discoloration  of  the  skin,  or 
marked  debility,  during  life. 

In  the  present  paper,  Dr.  Wilks,  who  has  already  shown  himself  to  be  a 
firm  believer  in  the  existence  of  the  morbus  Addisonii,  purposes  to  strengthen 
the  original  facts  contained  in  Dr.  Addison's  treatise,  by  fresh  instances, 
and  also  to  define  more  precisely  the  pathological  characters  of  the  disease. 
With  this  object  he  gives  the  details  of  twenty -five  cases  which  occurred  under 
his  own  observation,  or  in  which  he  examined  and  preserved  the  specimens, 
and  examines  critically  the  connection  existing  between  the  pathological 
condition  of  the  capsules,  and  the  presence  or  absence  of  certain  symptoms. 

When  he  published  his  work,  Dr.  Addison  believed  that  any  disease  that 
affected  the  integrity  of  the  supra-renal  capsules  would  be  attended  by  the 


126 


Reviews. 


[Jan. 


remarkable  phenomena  which  he  described.  This,  from  more  extensive 
observation,  Dr.  Wilks  is  satisfied  can  no  longer  be  maintained,  and  he 
attributes  to  this  mistake,  on  the  part  of  Dr.  Addison,  a  great  deal  of  the 
scepticism  existing  in  the  profession  on  the  subject.  According  to  him, 
there  is  only  one  disease  of  the  capsules  that  accompanies  these  phenomena, 
and  of  this  he  gives  the  following  description :  First,  the  organ  is  some- 
what enlarged,  and  changed  into  a  material  that  is  semi-translucent,  of  a 
gray  colour,  softish,  homogeneous,  and,  when  examined  microscopically,  is 
found  to  be  without  structure,  or  sometimes  slightly  fibrillated,  or  contain- 
ing a  few  abortive  nuclei  or  cells.  Subsequently,  this  lardaceous  kind  of 
material,  which  resembles  what  is  often  seen  in  the  early  stages  of  scrofu- 
lous enlargement  of  the  lymphatic  glands,  undergoes  a  decay  or  degenera- 
tion, and  chauges  into  an  opaque,  yellowish  substance.  At  a  still  later 
period  this  may  soften  into  a  putty-like  matter,  or  it  may  dry  up,  leaving 
the  mineral  part  as  a  chalky  deposit  scattered  through  the  organs.  For 
the  production  of  the  changes  thus  detailed  some  years  are  necessary.  ' 

If  it  be  admitted,  for  the  moment,  that  the  discoloration  of  the  skin,  upon 
which  so  much  stress  is  laid  in  the  morbus  Addisonii,  always  accompanies 
this  peculiar  morbid  condition  of  the  capsules,  it  will  be  necessary  to  admit 
that  the  affection  must  have  lasted  already  some  considerable  time,  and 
that  it  occasionally  in  fact  proves  fatal  before  the  discoloration  is  effected. 
The  eighth  case  detailed  by  Dr.  Wilks  is  one  in  point.  We  will  give  its 
main  features  as  briefly  as  possible.  Henry  M.  M — ,  set.  38,  had  for  twelve 
months  been  failing  ;  his  principal  complaint  being  pains  in  the  limbs  and 
general  debility.  He  died  about  two  weeks  after  admission  into  Guy's  Hos- 
pital, with  symptoms  of  utter  prostration.  On  examination  of  the  body,  the 
heart,  stomach,  liver,  spleen,  kidneys,  and  brain  were  found  healthy.  Scat- 
tered through  the  lungs  was  found  a  number  of  yellowish  deposits,  about 
the  size  of  peas,  hard,  and  somewhat  translucent  in  appearance.  The  supra- 
renal capsules  were  entirely  destroyed,  and,  when  cut  in  two,  they  presented 
no  appearance  of  structure.  The  adventitious  material  taking  the  place  of 
their  normal  elements,  was  in  some  parts  translucent,  and  in  others,  where 
it  had  undergone  probably  further  changes,  it  resembled  exactly  the  uniform 
yellow  material  which  is  so  commonly  seen  in  lymphatic  glands,  and  called 
scrofulous.  In  this  case,  where,  as  will  be  noticed,  the  disease  of  the  cap- 
sules was  well  marked,  and  wh-ere,  moreover,  the  other  organs  of  the  body 
were  healthy,  with  the  exception  of  some  deposits  in  the  lungs,  no  discolora- 
tion whatever  was  discovered  in  any  part  of  the  skin.  From  such  a  case 
as  this  it  must  be  decided  either  that  the  skin  becomes  discolored  after  this 
peculiar  disease  of  the  capsules  has  lasted  for  some  time,  or  that  this  pecu- 
liar disease  of  the  capsules  is  not  always  accompanied  by  a  bronzed  skin. 
We  have  not  come  to  the  same  conclusion  as  Dr.  Wilks  in  the  matter,  and 
very  probably  because  our  wills  are  not  the  same ;  for  in  such  circumstances 
it  is  generally  true  that  voluntas  pro  ratione  stet.  In  the  case  just  related, 
where  the  patient  died  with  all  the  organs  sufficiently  healthy,  except  the 
supra-renal  capsules,  the  demonstrator  of  morbid  anatomy,  the  teacher  of 
pathological  anatomy,  will  attribute  the  fatal  termination  of  the  case,  the 
result  of  extreme  debility,  to  the  organ  found  diseased.  We  saw  many  men 
die  last  summer,  whose  skins  were  as  dark  as  the  skin  of  a  mulatto,  with 
symptoms  of  extreme  prostration,  and  after  death  not  a  single  organ  in  the 
body  was  found  diseased.  AVith  the  exception  of  a  greater  quantity  of 
pigment  here  and  there,  perhaps  more  often  deposited  in  the  supra-renal 
capsules  than  elsewhere,  there  was  nothing  abnormal  to  be  found,  as  a 


1863.] 


Guy's  Hospital  Reports. 


12t 


general  rule,  in  the  bodies  of  those  who  diecl  of  the  so-called  Chickahominy 
fever.  This  was  so  markedly  the  case,  that  Professor  Leidy,  who  made 
the  post-mortem  examinations  we  refer  to,  has  declared  to  us  never  to  have 
seen  so  many  perfectly  healthy  organs  as  in  those  bodies. 

As  regards  the  second  great  objection,  that  discoloration  of  the  skin  has 
existed  without  disease  of  the  supra-renal  capsules,  this  Dr.  Wilks  frankly 
admits,  adding,  however,  that  he  believes  cases  of  the  kind  to  be  remark- 
ably few,  and  that  it  should  be  remembered  that  the  pigmentation  of  the  skin 
always  occurs  in  the  rete-mucosum,  and  probably  may  arise  from  several 
causes.  4 

To  answer  the  two  remaining  objections  brought  forward  to  show  that  the 
supra-renal  capsules  are  not  vital  organs,  namely,  that  they  can  be  removed 
with  impunity  from  the  lower  animals,  and  that  they  have  been  found  dis- 
eased in  the  bodies  of  men  who  died  from  accident  or  acute  disease,  in 
apparent  health,  Dr.  Wilks  gives  it  as  his  opinion  that  these  organs,  when 
diseased,  cause  death  by  implicating  the  adjacent  organic  nerves.  There  is 
nothing,  however,  to  support  this  opinion  in  the  details  of  the  post-mortem 
examinations  attached  to  the  cases  recorded ;  in  all  of  them  whenever  the 
condition  of  the  semi-lunar  ganglia  is  noticed,  it  is  stated  that  they  appeared 
healthy.  We  would  particularly  call  attention  to  this  fact,  in  the  history 
of  Case  XII.  where  this  report  is  made  of  these  ganglia,  and  the  patient  had 
had  discoloration  of  the  skin  for  three  years,  and  therefore,  according  to 
Dr.  Wilks,  complete  disorganization  of  the  supra-renal  capsules  for  more 
than  that  period. 

Though  the  study  of  this  paper  of  Dr.  Wilks  must  afford  gratification 
and  instruction,  we  doubt  whether  it  will  alter  the  views  of  any  member  of 
the  profession  who  does  not  already  believe  in  the  existence  of  the  morbus 
Addisonii.  • 

II.  Case  of  Tumour  at  the  Base  of  the  Brain;  with  Ophthalmic  and 
Post-mortem  Examination  of  the  Eyes.    By  C.  Bader. 

This  case  is  one  where  a  man  died  with  most  decided  symptoms  of  cere- 
bral mischief,  amongst  which  was  impairment  of  sight,  that  was  shown  by 
the  ophthalmoscope,  before  death,  to  be  accompanied  by  an  enlarged  and 
tortuous  state  of  the  veins  of  both  retinae.  Notwithstanding  the  very  con- 
siderable venous  congestion  of  the  retina,  both  it  and  the  optic  nerve  were 
apparently  unchanged  in  structure,  and,  according  to  the  ophthalmoscopic 
appearances,  the  amaurosis  was  to  be  attributed  to  something  else  than 
temporary  paralysis  from  pressure  within  the  eye.  An  undue  accumulation 
of  blood  at  the  base  of  the  brain,  from  some  cause  or  other,  was  supposed 
to  be  the  cause  of  this  condition  of  things. 

At  the  post-mortem  examination,  an  oval  tumour,  of  a  fibrous  nature, 
•  about  the  size  of  a  small  hen's  egg,  was  found  at  the  base  of  the  brain  on 
the  inner  and  lower  surface  of  the  right  lobe  of  the  cerebellum.  The  pons 
varolii  was  much  compressed,  and  likewise  the  upper  part  of  the  medulla 
oblongata. 

The  whole  account  of  the  ophthalmoscopic  examination,  with  the  reflec- 
tions of  Dr.  Bader,  are  exceedingly  interesting  : — 

M  The  media  (the  transparent  parts  in  front  of  the  retina)  transparent ;  retina, 
choroid,  and  sclera  normal,  except  the  bloodvessels  (veins)  of  the  retina,  which 
were  numerous,  gorged  with  blood,  and  tortuous  (elongated).  The  optic  nerve 
(at  the  choro-retinal  aperture)  of  the  left  eye  appeared  almost  as  red  as  the 
adjoining  choroid,  especially  its  temporal  portion  (inverted  image),  thus  appear- 
ing ill-defined,  i.  e.,  the  adjoining  choroidal  aperture  not  well  marked  off.  There 


128 


Reviews. 


[Jan. 


was  no  change  in  the  retinal  arteries  where  they  pass  through  the  nerve ;  the 
veins  were  as  numerous  and  gorged,  &c,  as  in  the  retina. 

"  In  the  right  eye  a  similar  state  of  the  veins  existed  in  a  still  higher  degree. 
The  situation  of  the  optic  nerve  (of  the  choro-retinal  aperture)  could  only  be 
recognized  by  the  vessels  of  the  retina  converging  towards  and  passing  through 
it ;  the  contours  of  the  aperture  were  observed  by  the  great  vascularity  of  the 
nerve  thus  blending  in  colour  with  the  choroid,  and  probably  changing  the  re- 
flection from  the  retina. 

"  A  similar  state  of  bloodvessels  in  the  retina  and  optic  nerve  I  have  noticed — 

"  (1)  In  chronic  forms  of  sub-retinal  dropsy  (these  were  excluded  by  the  trans- 
parent state  of  the  retina  and  the  healthy  appearance  of  the  choroid). 

"  (2)  In  retinitis  apoplectica  (there  were  no  apoplexies  in  this  case,  though 
they  might  have  appeared  finally  if  the  impairment  in  the  circulation  had 
continued). 

"  The  state  was  not  due  to  any  intra-ocular  pressure  (at  the  scleral  or  at  the 
choro-retinal  aperture),  because  the  veins  were  equally  (proportionately)  en- 
larged in  the  optic  nerve  and  in  the  retina,  and  there  was  no  anaemia  of  the  optic 
nerve.  It  might  have  been  ascribed  to  structural  changes  of  the  nerve  itself, 
but  the  latter,  in  those  cases,  is  generally  found  pearly  white  or  anaemic.  The 
other  cerebral  symptoms,  together  with  the  enlarged,  tortuous  state  of  the  veins 
of  both  the  retinae,  made  it  probable  that  an  undue  accumulation  of  blood  at  the 
base  of  the  brain  was  the  cause  of  the  state  of  the  bloodvessels  (veins)  of  the 
retina.  The  impairment  of  sight  could,  not,  according  to  the  ophthalmoscopic 
appearances,  be  attributed  to  a  temporary  paralysis  of  the  nerve  from  pressure, 
by  the  over-filled  bloodvessels  within  the  eye.  It  appears,  from  the  healthy 
state  of  the  retina  and  optic  nerve  (microscopically) ,  that  the  changes  at  the 
base  of  the  brain  were  the  cause  of  blindness.  Ophthalmoscopically,  it  was 
interesting  to  find  the  retina  and  optic  nerve  apparently  unchanged  in  structure 
with  such  considerable  venous  congestion  of  the  retina. 

"  The  indistinctness  of  the  optic  nerve  at  the  choro-retinal  aperture  I  attri- 
bute to  the  change  of  refractions  of  the  retina  at  this  part.  We  may  consider 
the  congestion  of  the  retina,  the  interior  of  the  eye  and  its  functions  being 
otherwise  normal,  a  valuable  means  of  recognizing  impairments  of  the  circulation 
at  the  base  of  the  brain.  It  would  be  interesting,  in  cases  of  brain  disease, 
whether  vision  be  impaired  or  not,  to  examine  the  retina  for  its  vascularity,  with 
a  view  of  watching  cerebral  changes  and  establishing  the  value  of  this  diagnos- 
tical  aid." 

After  death,  one  of  the  eyes  having  been  in  a  weak  solution  of  chromic 
acid  for  a  few  days,  was  examined  microscopically.  The  choroid  and  retina 
were  healthy  ;  the  elements  of  the  latter  were  well  seen,  and  their  relative 
position  not  in  the  slightest  degree  disturbed ;  there  were  no  signs  of  pres- 
sure at  the  retinal  aperture  ;  the  optic  nerve  appeared  equally  healthy  ;  the 
connective  tissue,  the  individual  nerve-fibres,  and  the  bundles  of  nerve-fibres, 
the  piles  of  nuclei  between  the  fibres,  the  relative  position  of  these  elements 
to  the  retina,  &c,  was  undisturbed. 

III.  and  IV.  Remarks  on  the  Stereoscopic  Theory  of  Vision,  with 
Observations  on  the  Experiments  of  Professor  Wheatstone.  Section  I. 
The  Stereoscope  and  Stereoscopic  Results.  Section  II.  By  Joseph 
Tyrone. 

The  experiments  related  in  these  papers  are  of  great  importance.  If  they 
are  indeed  as  conclusive  as  they  appear  to  us  to  be,  we  do  not  understand 
how  it  is  possible  to  reconcile  the  results  obtained  with  the  stereoscopic 
theory  of  vision. 

The  following  observations  upon  the  stereoscopes  in  ordinary  use,  and 
the  description  of  the  one  recommended  will  be  found  very  interesting. 

"  Pictures,  when  seen  in  the  stereoscope,  are  referred  principally  to  the  inner 


1863.] 


Guy's  Hospital  Reports. 


129 


tracts  of  the  two  retin&,  while  in  ordinary  vision  these  tracts  cannot  act  in  concert, 
the  impressions  upon  the  inner  side  of  the  right  eye,  and  upon  the  inner  side  of  the 
left  eye  being  distinct,  and  their  images  referred  in  opposite  directions.  It  would 
be  premature  to  conclude  that  this,  of  necessity,  involves  a  fallacy ;  but  it  must, 
I  think,  be  considered  as  a  fact  of  some  significance.  Neither  can  the  form  of 
the  stereoscopic  lenses  be  disregarded.  It  is  to  be  observed  that  these  lenses 
are  so  constructed  as  to  combine  the  properties  of  the  convex  lens  with  those 
of  the  prism,  the  result  of  this  arrangement  being,  that  the  two  pictures  when 
viewed  in  the  stereoscope,  are  displaced,  that  seen  by  the  right  eye  a  little  to 
the  left,  and  that  seen  by  the  left  eye  a  little  to  the  right.  So  far,  therefore,  as 
the  superposition  of  the  two  stereoscopic  pictures  is  assisted  by  this  means,  the 
result  is  optical,  not  ocular,  and  must  be  referred  to  the  instrument,  not  to  the 
eyes.  These  observations  apply  to  the  lenticular  stereoscope  of  Sir  David 
Brewster,  which,  admirable  though  it  be  for  popular  use,  for  scientific  purposes 
is  inferior  to  the  original  reflecting  stereoscope  of  Mr.  Wheatstone.  Still  I 
must  confess  that  very  early  in  these  inquiries  I  became  conscious  of  a  necessity, 
for  some  method  of  investigation  less  artificial  in  character,  and  less  restricted 
in  its  operations  than  any  yet  introduced.  These  advantages  have  been  secured 
by  means  of  an  instrument  I  have  constructed  for  the  purpose,  which  since  it  is 
essential  to  some  of  the  experiments  hereafter  to  be  introduced,  and  also  affords 
increased  facilities  for  similar  observations,  I  will  at  once  describe,  under  the 
name  of  the  adjustive  stereoscope.  This  instrument  consists  of  a  board,  which 
forms  the  bottom,  having  sides  and  ends  ;  in  length  it  is  16  inches,  in  width  7. 
inches  ;  the  sides  are  1  inch  deep,  and  the  ends  5  inches  deep,  the  one  to  admit 
of  space  for  the  eye-holes,  the  other  is  fitted  with  grooves  to  receive  the  slides  ; 
the  end  for  the  eye-holes  is  fixed,  that  for  the  slides  must  allow  of  being  moved 
backwards  or  forwards,  for  the  regulation  of  distance.  The  distance  between' 
the  centres  of  the  eye-holes  is  2£  inches ;  these  openings,  instead  of  containing 
lenses,  are  covered  with  two  thin,  brass  plates,  there  being  in  each  plate  a  small 
perforation  like  a  pinhole ;  these  two  apertures  must  be  brought  exactly  oppo- 
site the  two  pupils,  and  since  the  distance  between  the  pupils  varies  in  different 
individuals  the  eye-plates  are  made  to  slide  in  grooves,  so  that  they  can  be 
readily  adjusted  to  the  eyes  of  different  persons.  The  plates  are  on  the  outer 
side  of  the  openings,  that  is,  they  are  placed  before  the  openings.  (Plate.) 

The  eyes  should  be  brought  close  to  the  apertures,  and  a  thumb  placed  on 
either  plate,  when,  by  slight  lateral  motion,  the  apertures  may  be  readily  ad- 
justed to  the  pupils,  and  they  are  so,  when  the  right  image  is  seen  exclusively 
with  the  right  eye  alone,  and  the  left  image  is  seen  exclusively  with  the  left  eye 
alone ;  these  conditions  being  secured,  if  both  eyes  be  opened,  the  images  will 
be  superposed.  The  inside  of  the  instrument  is  to  be  painted  black,  and  there 
are  several  points  connected  with  its  use  which  require  particular  attention,  and. 
on  their  due  observance  the  integrity  of  its  operations  depends  ;  first,  and  prin- 
cipally, upon  the  exact  adjustment  of  the  eye-plates,  and  second  to  this,  but 
scarcely  less,  upon  the  arrangement  of  the  light.  I  shall,  therefore,  add  a  few 
words  upon  these  two  points.  The  plates  should  be  of  thin  bra§s,  their  dimen- 
sions three  and  a  half  inches  by  one  and  a  half  inch ;  it  is  essential  that  the 
apertures  should  be  clear  at  their  edges  and  free  from  shine  or  glitter,  and  the 
grooves  in  which  they  slide  must  be  perfectly  true,  so  that  when  the  apertures 
are  brought  before  the  two  pupils,  they  may  appear  as  one  opening.  Care  should 
be  taken  to  secure  a  sufficient  and  equal  light  upon  the  objects,  while  the  eyes 
are  kept  in  shadow ;  under  a  lamp  this  may  be  easily  managed,  by  having  the 
side  of  the  lamp  next  the  observer  covered,  while  the  light  falls  upon  the  objects, 
and  by  daylight  the  same  advantage  can  be  secured  by  turning  the  back  to 
the  window,  so  that  the  eyes  are  in  shadow  while  the  objects  are  well  illumi- 
nated." 

This  paper  is  abundantly  illustrated  with  wood-cuts,  some  of  them 
coloured,  and  a  plate  is  attached  representing  an  outline  drawing  of  the 
adjustive  stereoscope  just  described. 

No.  LXXXIX.— Jan.  1863.  9 


130 


Reviews. 


[Jan. 


Y.  Clinical  Notes  on  some  Cases  of  Disease  of  the  Heart.  By  S.  0. 
Habershon,  M.  D. 

This  paper  contains  the  detailed  histories  of  eight  cases  of  cardiac  dis- 
ease, with  general  remarks  attached  to  each  one.  It  is  particularly  worthy 
of  attention  on  account  of  the  judicious  treatment  recommended  in  chronic 
cardiac  disease.  By  care  as  to  diet  and  the  state  of  the  bowels,  so  as  to 
avoid  flatulence  and  hepatic  congestion,  by  attention  to  the  atmospheric 
condition  so  as  to  guard  against  recurrent  attacks  of  bronchitis,  and  by 
regulating  the  muscular  exercise  of  the  patient,  more  can  be  done  to  retard 
the  increase  and  the  speedy  termination  of  such  disease  than  by  any  adminis- 
tration of  medicines. 

This  paper  is  illustrated  by  a  plate  representing  an  aneurism  of  the  aorta 
that  opened  into  the  pulmonary  artery. 

YI.  Notes  of  Several  Cases  in  which  Podophyllin  was  used  as  a 
Purgative.    By  S.  0.  Habershon,  M.  D. 

The  cases  here  related  are  twelve  in  number,  and  of  various  diseases.  In 
none  of  them  is  there  anything  remarkable  in  regard  to  the  peculiar  action 
of  podophyllin ;  but  we  may  notice  a  typographical  error  in  the  paper — 
the  United  States  Dispensatory  is  referred  to  as  the  work  of  "Wood  and 
Barker." 

YII.  Two  Cases  of  Extra-uterine  Fcetation,  treated  by  Abdominal 
Section.    By  J.  Braxton  F.  Hicks,  M.  D.  F.  R  S. 

There  are  several  points  in  connection  with  cases  of  extra-uterine  preg- 
nancy upon  which  the  profession  is  still  seeking  information. 

We  know  that  the  life  of  the  child  is  not  to  be  considered,  for  in  every 
instance  where  an  attempt  has  been  made  to  extract  the  child  while  living, 
the  mother  has  been  destroyed.  We  know  again,  that  when  the  operation 
is  performed,  the  placenta  should  not  be  interfered  with  if  at  all  adherent ; 
but  the  propriety  of  performing  an  operation,  and  the  most  advantageous 
period  for  performing  it  are  still  in  question. 

There  are  so  many  cases  on  record  where  the  foetus  has  remained  innocu- 
ous for  an  indefinite  period,  in  some  for  more  than  fifty  years,  and  the 
instances  are  so  numerous  where  the  foetus  has  been  got  rid  of  by  ulceration 
into  the  vagina,  bladder,  and  intestines,  as  well  as  by  abscess  opening  ex- 
ternally either  at  the  umbilicus  or  some  other  part  of  the  abdominal  walls, 
that  the  surgeon  must  hesitate  before  he  consents  to  perform  an  operation 
attended  with  so  much  danger  as  that  of  gastrotomy.  As  to  the  proper 
time  of  performing  the  operation,  that  must  be  decided  mainly  by  the  pro- 
babilities of  adhesions  having  been  formed  between  the  cyst  and  the  walls 
of  the  abdomen.  In  fact,  we  feel  inclined  to  believe  that  the  operation 
should  never  be  undertaken  until  the  surgeon,  if  not  confident  of  the  exist- 
ence of  such  adhesions,  has  made  an  effort  to  establish  them,  as  we  have 
several  times  seen  effected  in  cases  of  hydatid  cysts  of  the  liver,  by  the 
application  of  Yienna  paste.1 

In  one  of  the  two  cases  related  by  Dr.  Hicks,  as  well  as  we  can  judge, 
for  the  last  menstrual  period  is  not  stated,  the  full  term  had  expired  about 
eight  months  at  the  time  of  operation ;  in  this  case  the  cyst  which  com- 
municated with  the  intestine  was  not  adherent,  and  the  patient  died  in 
twelve  hours  after  the  operation.    In  the  second  case,  the  full  term  had 


'  See  Nelaton's  Clinical  Lectures  on  Surgery,  Phila.  1855,  page  531,  &c. 


1863.] 


Guy's  Hospital  Reports. 


131 


expired  about  four  years ;  the  cyst,  which  communicated  with  the  bladder, 
was  completely  adherent,  and  the  patient  recovered. 

From  the  general  remarks  made  by  Dr.  Hicks  upon  these  cases,  we  think 
it  well  to  make  the  following  extract,  though  we  prefer  to  the  proceeding 
advocated  by  him,  the  plan  we  have  referred  to  above : — 

"  It  seems  therefore,  to  me,  that  in  all  cases  where  there  is  no  adhesion,  or 
only  a  partial  one,  between  the  cyst  and  the  parietes,  it  would  be  the  safest, 
indeed  imperative,  to  sew  the  free  lips  of  the  wound  in  the  cyst  to  the  corres- 
ponding side  of  the  abdominal  walls,  before  any  attempt  is  made  at  the  extraction 
of  the  foetus.  To  prevent  the  escape  of  the  fluid  contents,  during  this  per- 
formance, into  the  peritoneal  cavity,  will,  of  course,  require  care,  but  it  might 
be  accomplished  by  seizing  the  cyst  with  a  vulcellum,  while  the  opening  into  it 
is  made  quickly  of  the  desired  length.  Then  momentarily  upon  the  formation 
of  this,  the  finger  of  the  operator  upon  one  side,  and  of  an  assistant  on  the 
other,  could  enter  the  wound,  and  hold  the  edges  in  contact  with  those  of  the 
external  opening.  This  point  being  secured,  a  sufficient  number  of  sutures 
could  then  be  made  use  of  to  secure  perfect  apposition  throughout  the  length 
of  the  wound.  Should  air  be  in  the  cyst,  as  in  these  two  cases,  the  above  might 
be  accomplished  with  much  more  ease.  Care  of  course  should  be  taken  not  to 
include  any  intestine  or  omentum.  After  the  peritoneum  is  thus  shut  off,  the 
foetus  should  be  extracted  as  carefully  as  possible,  in  whatever  manner  is 
easiest,  according  to  its  relation  to  the  opening." 

VIII.  Notes  on  Two  Cases  of  Uterine  Polypi.  By  J.  Braxton 
Hicks,  M.  D.  F.  R.  S. 

The  first  of  the  two  cases  related  in  this  paper  is  chiefly  interesting  in 
a  pathological  point  of  view.  A  globular  polypus,  removed  from  the  os 
uteri,  was  found,  when  microscopically  examined,  to  contain,  in  a  certain 
portion  of  its  tissue,  caudate  cells,  inclosing  two  or  three  nuclei,  differing 
much  in  size.  It  was,  therefore,  according  to  Dr.  Hicks,  to  be  looked  upon 
as  bearing  a  close  affinity  to  the  more  marked  forms  of  malignant  disease. 
At  the  expiration  of  eighteen  months,  the  patient  applied  to  Dr.  Hicks  again 
on  account  of  a  tumour,  attached  to  the  uterus,  and  extending  nearly  to 
the  umbilicus.  She  soon  afterwards  died  suddenly,  from,  as  it  afterwards 
appeared,  fatty  heart.  On  examining  the  growth,  it  was  found  to  be  much 
softer  in  the  upper  portion  than  in  the  lower,  and  to  be  formed  there  of  large 
nucleated  fibre-cells,  together  with  cells  similar  to  those  described  as  occur- 
ring in  the  polypus  first  removed. 

The  second  case  is  interesting  chiefly  in  a  practical  point  of  view,  as  an 
instance  of  the  ease  and  rapidity  with  wich  the  removal  of  an  intra-uterine 
polypus  may  be  effected  by  means  of  the  annealed  steel  wire-rope  ecraseur. 

IX.  On  Stricture,  Retention  of  Urine,  Stone  in  the  Bladder,  and  other 
Diseases  of  the  Urinary  Organs,    By  Thomas  Bryant. 

This  is  the  fourth  of  the  series  of  articles,  being  published  by  Mr.  Bryant 
in  the  Reports,  which  are  intended  to  illustrate,  from  cases  that  have  occurred 
in  Guy's  Hospital,  the  surgery  of  the  different  regions  of  the  body.  In 
preceding  articles,  the  surgery  of  the  nervous,  the  respiratory,  the  circula- 
tory, and  the  digestive  organs  have  been  freely  illustrated  from  the  very 
extensive  clinical  data  there  furnished. 

The  source  from  which  the  material  for  the  present  paper,  on  the  surgery 
of  the  genito -urinary  organs,  is  drawn,  is  thus  tabulated  : — 


132 


Reviews. 


[Jan. 


Simple  organic  stricture  .... 
"               "            with,  retention1 

336 

9 

345 

106 

3 

109 

"                "            with  extravasation  of 

urine  . 

30 

15 

45 

"                {t             with  urinary  fistula? . 

46 

1 

47 

Traumatic  stricture  and  its  complications 
Cases  of  "  external  division"  and  "  perineal 

34 

1 

35 

section"  ... 

36 

7 

43 

Cases  of  puncture  of  bladder  per  rectum 

20 

3 

23 

76 

4 

80 

19 

19 

Urethral  calculus  ...... 

12 

2 

14 

Irritable  bladder  

134 

2 

136 

Incontinence  of  urine  

22 

22 

19 

19 

Inflammation  of  the  prostate  .... 

6 

6 

Calculus  vesicae  

112 

22 

134 

Total 

1008 

69 

1077 

These  cases,  it  may  be  interesting  to  know,  were  admitted  into  Guy's 
Hospital,  from  October  1st,  1853,  to  March  31st,  1861,  or  in  a  period  of 
^seven  and  a  half  years. 

Spasmodic  stricture  is  treated  of  by  Mr.  Bryant  in  the  chapter  on  re- 
tention of  urine,  and  he  begins  his  paper  by  the  consideration  of  organic 
or  permanent  stricture,  under  which  head  he  includes  both  those  strictures 
resulting  from  chronic  inflammation  in  the  urethra,  styled  simple  organic 
stricture  and  those  usually  called  traumatic,  that  is,  following  a  partial  or 
complete  rupture  of  the  canal  from  external  or  internal  violence. 

As  respects  the  locality  of  simple  organic  stricture,  he  agrees  entirely 
with  the  views  of  Mr.  Thompson,  with  the  results  of  whose  investigations 
the  readers  of  this  journal  are  familiar. 

In  inquiring  into  the  causes  of  stricture,  out  of  the  646  cases,  it  is  found 
that  gonorrhoeal  inflammation  had  existed  in  273  instances,  or  42  per 
centum  ;  and  direct  injury  was  the  assigned  cause  in  43,  or  6.6  per  centum  ; 
leaving  330,  or  more  than  one-half,  in  which  no  definite  cause  could  be  dis- 
covered. Out  of  the  273  cases  in  which  a  gonorrhoea  had  previously  existed, 
in  78,  or  28  per  centum,  injections  had  been  employed. 

Of  the  603  cases  of  simple  organic  stricture,  565  were  treated  by  simple 
dilatation  of  the  urethra,  and  38  by  some  operation  opening  the  urethra  in 
the  perineum.  Of  the  43  cases  of  traumatic  stricture,  37  were  treated  by 
dilatation,  and  6  by  opening  the  urethra  into  the  perineum.  It  is  thus 
seen  in  that  both  simple  and  traumatic  organic  stricture,  dilatation  is  the 
treatment  most  generally  employed  in  Guy's  Hospital,  and  that  the  knife  is 
only  resorted  to  in  exceptional  cases. 

The  internal  division  of  the  stricture  receives  but  little  support  at  Guy's 
Hospital.  It  was  only  performed  in  five  of  these  cases,  and  in  all  of  these 
the  stricture  existed  either  at,  or  within  an  inch  of,  the  urethral  orifice.  The 
plan  of  treatment  by  means  of  caustics,  has  met  with  even  less  support  than 
the  one  just  mentioned. 

"  External  division,"  the  operation  so  much  lauded  by  Professor  Syme, 
was  had  recourse  to  in  7  cases  of  uncomplicated  organic  stricture,  where 
dilatation  failed  from  the  too  great  irritability  or  too  obstinate  contractility 
of  the  stricture. 

In  those  very  rare  cases  where  all  local  and  constitutional  treatment  fails 
in  affording  relief,  and  the  stricture  is  impermeable,  Mr.  Bryant  believes 


1863.] 


Guy's  Hospital  Reports. 


133 


"  perineal  section"  to  be  the  best  operation  to  resort  to.  For  performing 
this  difficult  operation,  the  plan  originally  planned  and  executed  by  Mr. 
Cock  is  recommended.  v  For  its  performance  the  following  directions  are 
given : — 

"  Having  placed  the  patient  in  the  position  for  lithotomy,  pass  the  finger  of 
the  left  hand  into  the  rectum,  and  apply  its  point  to  the  anterior  margin  of  the 
prostate  and  membranous  portion  of  the  urethra — a  part  which  it  is  not  difficult 
to  detect  even  in  the  most  diseased  urethras.  A  straight  knife,  with  the  edge 
turned  upwards,  should  then  be  passed  through  the  centre  of  the  perineum, 
directly  backwards  to  the  apex  of  the  urethral  triangle  or  anterior  margin  of  the 
prostate  :  this  point  being  readily  detected  by  the  finger  already  resting  in  the 
rectum ;  an  incision  of  the  whole  thickness  of  the  parts  should  then  be  made 
upwards,  the  canal  being  freely  opened  and  the  stricture  divided.  By  this 
means  the  urethra  cannot  fail  to  be  freely  opened,  and  it  only  requires  care  on 
the  part  of  the  surgeon  to  divide  the  whole  stricture  throughout  its  full  extent. 
With  a  grooved  probe  the  vesical  orifice  of  the  urethra  may  then  be  found,  and 
a  catheter,  having  been  passed  down  the  penis  through  the  divided  stricture, 
should  then  be  introduced  into  the  bladder,  and  left  in." 

Fifty-five  of  the  cases  of  simple  organic  stricture,  and  three  of  those  of 
traumatic  stricture,  were  complicated  with  extravasation  of  urine.  In 
such  cases,  giving  rise  to  urinary  abscess,  many  surgeons  are  satisfied  with 
merely  opening  the  abscess  in  the  perineum,  leaving  the  stricture  to  be  sub- 
sequently treated  by  dilatation  or  by  other  means.  The  soundest  and  most 
correct  practice,  according  to  Mr.  Bryant,  is  to  divide  the  stricture,  at  the 
same  time  that  the  abscess  is  opened.  In  some  severe  cases  of  extravasa- 
tion, where  the  urine  is  extensively  infiltrated,  he  directs  free  incisions  to 
be  made  into  the  infiltrated  parts,  and  the  "  perineal  section"  to  be  per- 
formed without  delay,  in  order  to  divide  the  stricture  and  to  remove  the 
obstruction  to  the  flow  of  urine. 

Sixty-five  of  the  cases  of  simple  organic  stricture  were  complicated  with 
urinary  fistula.  In  forty-seven  a  cure  was  obtained  by  dilatation  ;  in  the 
remaining  eighteen  either  the  operation  of  perineal  section  or  of  external 
division  was  found  necessary. 

The  treatment  recommended  by  Mr.  Bryant  in  cases  where  the  stricture 
is  traumatic  is  the  same  as  that  where  it  is  organic.  Qf  course  the  perma- 
nent effect  of  dilatation  is  not  nearly  so  great ;  out  of  the  forty -three  cases 
tabulated,  in  six  the  operation  of  perineal  section  or  of  external  division 
was  absolutely  required. 

The  following  is  the  analysis  of  the  cases  of  perineal  section  and  external 
division : —  * 
Cases  of  external  division : — 

Seven  cases  for  irritable  and  contractile  strictures;  one  of  which  died 
from  renal  disease  and  uraemic  poisoning. 

Five  cases  for  stricture  and  extravasation ;  all  recovered. 

Four  cases  for  stricture  and  perineal  fistula;  all  did  well. 

Three  cases  of  external  division  for  traumatic  stricture  or  its  complica- 
tions; all  recovered. 

Cases  of  perineal  section : — 

Five  cases  for  stricture  and  extravasation ;  of  which  one  died. 

Fourteen  cases  for  stricture  and  perineal  fistula;  two  died. 

Three  cases  for  traumatic  stricture  and  complications ;  two  died. 

Two  cases  for  obstructed  or  impermeable  urethra ;  one  died. 

The  chapter  on  retention  of  urine  contains  some  remarks  upon  retention 
as  a  result  of  elongated  and  adherent  prepuce  that  will  be  novel  to  most 


134 


Reviews. 


[Jan. 


surgeons.  Mr.  Bryant  says  that  he  could  quote  cases  in  which  an  adherent 
prepuce  had  been  the  cause  of  retention  and  of  incontinence  of  urine,  and 
had  produced  every  symptom  of  a  vesical  calculus,  even  hsematuria.  In 
his  belief,  in  at  least  two-thirds  of  the  cases  of  children  suffering  from 
urinary  irritation,  the  sole  cause  is  an  adherent  and  elongated  prepuce;  and 
the  only  remedy  is  circumcision  and  the  careful  separation  of  the  prepuce 
from  the  glans  penis,  with  the  removal  of  the  confined  secretion  of  Tyson's 
glands.  Though  inclined  for  many  good  reasons  to  favour,  in  every  legiti- 
mate way,  the  practice  of  the  excellent  institution  of  circumcision,  we  can- 
not but  believe  the  true  cause  in  such  cases  to  be  rather  a  narrow  orifice 
in  the  prepuce  than  the  elongation  and  adhesion  to  the  glans. 

As  a  final  conclusion  to  this  chapter,  Mr.  Bryant  declares  "that  in  all 
cases  of  retention  of  urine  from  stricture,  in  which  relief  cannot  be  given 
by  means  of  rational  and  not  forcible  catheterism,  and  in  which  the  use  of 
the  warm  bath  and  opium  have  fairly  failed,  the  operation  of  puncturing 
the  bladder  through  the  rectum  is  to  be  performed."  To  the  use  of  the 
warm  bath  and  opium,  that  of  chloroform  and  ether  should  be  added;  Mr. 
Bryant  has  evidently  forgotten  to  mention  them. 

The  causes  of  death  in  the  thirty-six  cases  of  stricture  in  which  a  fatal 
result  took  place,  were  as  follows :  In  twenty-six  a  post-mortem  examina- 
tion was  made,  and  in  all  diseased  kidneys  were  discovered ;  not  such  disease 
as  requires  microscopical  research  for  its  detection,  but  positive  destructive 
and  suppurative  disease  of  the  organs ;  and  of  the  remaining  ten,  two  died 
with  evident  symptoms  of  ursemic  poisoning,  and  in  the  other  eight  that 
most  marked  exhaustion  which  appears  so  characteristic  of  renal  disease 
was  present.  The  duration  of  the  stricture  has  necessarily  a  serious  influ- 
ence in  producing  a  fatal  result ;  the  longer  the  obstruction  exists,  the 
greater  the  probability,  if  not  certainty,  of  the  production  of  renal  disease. 
In  these  thirty-six  fatal  cases  the  average  duration  of  the  stricture  was 
seventeen  years. 

In  the  nineteen  cases  of  ruptured  urethra,  in  the  majority  of  instances 
the  injury  was  caused  by  some  direct  violence  to  the  perineum,  but  in  some 
the  injury  was  produced  by  the  passage  of  a  cart-wheel  across  the  pelvis. 
It  is  somewhat  difficult  to  understand  how  such  a  result  can  be  thus  pro- 
duced without  a  fracture  of  the  pubic  portion  of  the  pelvis;  but  it  is  never- 
theless true  that  such  cases  are  occasionally  met  with.  The  practice  recom- 
mended by  Mr.  Bryant  is  eminently  judicious. 

"If  called,  therefore,  to  a  patient  who  has  evidently  been  the  subject  of  an 
injury  to  the  urethra,  suffering  from  simple  retention,  the  first  object  of  the  sur- 
geon should  be  to  attempt  to  pass  a  catheter ;  if  the  urethra  is  not  completely 
torn  away,  and  there  is  not  much  blood  locally  effused,  there  will  be  a  strong 
probability  that  he  will  succeed,  and  having  done  so,  the  instrument  should  be 
left  and  fastened  in  ;  a  gum-elastic  instrument,  therefore,  with  a  strong  stilette, 
should  be  employed.  If  the  attempt  at  catheterism,  although  having  been  fairly 
made,  should  fail,  some  other  means  must  be  employed,  for  it  is  clear  that  an 
outlet  for  the  urine  must  be  obtained,  or  ottenvise  extravasation,  with  its  dan- 
ger, will  necessarily  follow.  9 

"An  incision  into  the  perineum  with  a  grooved  staff  is  unquestionably  the 
soundest  practice ;  by  it  the  extravasated  blood,  and  urine  if  it  exists,  finds  a 
ready  outlet,  and  the  bladder  when  it  contracts  will  find  a  vent  for  its  contents, 
without  the  dangers  occasioned  by  an  extravasation  of  urine. 

"If  the  orifice  of  the  vesical  end  of  the  ruptured  urethra  can  be  found  with 
a  grooved  probe,  a  catheter  should  be  passed,  the  instrument  having  been  first 
introduced  through  the  penis,  and  subsequently  guided  upon  the  grooved  probe 
into  the  bladder;  if  difficulty  is  experienced  in  finding  the  orifice,  there  need  be 


1863.J 


Guy's  Hospital  Reports.  135 


no  alarm,  as  it  is  quite  clear  that  the  urine  will  readily  find  its  way  externally 
through  the  artificial  wound ;  an  early  attempt  to  pass  a  catheter  should,  never- 
theless, certainly  be  made,  for  it  is  most  important  that  the  continuity  of  the 
urethra  should  be  restored  as  early  as  possible. 

"When  a  catheter  has  been  introduced,  it  must  be  left  in;  for  it  is  equally 
important  that  the  patency  of  "the  canal  should  be  maintained  during  the  whole 
period  of  its  repair,  and  its  subsequent  contraction  in  a  measure  neutralized. 
The  frequent  passage  of  an  instrument  after  the  repair  has  taken  place,  is  an 
important  point  to  be  observed;  this  practice  being  the  best  guarantee  that  a 
traumatic  stricture  will  not  be  the  result,  and  if  it  be,  its  risks  will  be  materially 
lessened." 

Of  the  fourteen  cases  of  impacted  urethral  calculus,  only  three  were  in 
adults,  and  the  remaining  eleven  were  in  children.  In  the  adults  the  stone 
was  immediately  behind  the  glans  penis,  and  was  readily  removed  through 
the  urethra.  In  only  one  case,  in  the  children,  had  the  stone  passed  as  far 
as  the  penis;  in  all  the  others  it  had  remained  fixed  in  the  perineum,  and 
in  five  of  the  cases  extravasation  of  urine  had  already  occurred.  The  prac- 
tical point  for  recollection  is  this :  that  in  children  extravasation  of  urine 
is  almost  certainly  the  result  of  an  impacted  calculus,  and  that  an  early 
perineal  incision  is  the  only  sound  treatment. 

The  chapters  treating  of  irritable  and  inflamed  bladder  in  children  and 
in  adults,  incontinence  of  urine,  hsematuria,  and  inflammation  and  ab- 
scess of  the  prostate,  contain  valuable  practical  observations,  but  nothing 
calling  here  for  special  remark. 

The  last  chapter  in  Mr.  Bryant's  interesting  paper  is  on  stone  in  the 
bladder.  The  whole  number  of  cases  recorded  in  the  table  is  134.  Of 
these — 

"  In  two  cases  the  calculus  was  passed  per  urethra. 

In  seventeen  cases  lithotrity  was  performed,  and  one  died. 

In  ninety-six  cases  lateral  lithotomy  was  performed,  fourteen  proving  fatal. 

In  two  cases  lithotomy  was  called  for  after  lithotrity  had  failed,  one  case  dying. 

In  five  cases  median  lithotomy  was  executed,  and  in  these  cases  death  fol- 
lowed, the  operation  having  been  solely  undertaken  to  afford  relief. 

In  two  cases  median  lithotomy  was  performed  for  prostatic  calculi. 

In  one  case  the  recto-vesical  operation  was  successfully  performed  for  a  very 
large  calculus. 

In  nine  cases  no  operation  was  deemed  justifiable,  on  account  of  the  presence 
of  some  organic  disease,  three  dying  of  renal  disease  while  in  the  hospital." 

The  following  are  the  conclusions  drawn  from  these  cases,  concerning 
the  treatment  of  stone  in  the  bladder : — 

"  1.  That  in  all  cases  of  stone  in  the  bladder,  if  the  kidneys  are  sound,  the 
operations  of  lithotomy  or  lithotrity  are  likely  to  prove  successful. 

"2.  That  if  the  kidneys  are  diseased,  however  skilfully  may  either  operation 
be  executed,  a  fatal  result  will  probably  ensue. 

"3.  That  renal  disease,  if  not  capable  of  detection  by  the  examination  of  the 
urine,  can  tolerably  accurately  be  diagnosed  by  the  history  of  the  duration  of 
the  symptoms  ;  the  longer  their  existence  the  greater  the  probability  of  its  pre- 
sence, and  vice  versa. 

"4.  That  in  children  the  operation  of  lithotomy  is  almost  uniformly  successful, 
about  one  case  in  twenty  proving  fatal,  renal  disease  being  very  rare ;  and  that 
it  is  to  be  preferred  to  the  operation  of  lithotrity. 

"  5.  That  in  adults  free  from  organic  disease,  lithotrity  is  a  most  valuable 
operation,  and  is  to  be  preferred  to  lithotomy,  unless,  from  the  size  and  nature 
of  the  calculus,  or  from  any  peculiarity  in  the  patient,  there  are  strong  reasons 
for  its  rejection. 

"6.  That  lithotomy  in  adults  between  puberty  and  forty  years  of  age,  is  fatal 


136 


Reviews. 


[Jan. 


in  one  case  out  of  seven ;  and  after  that  age  in  one  case  out  of  one  and  three- 
quarters  ;  renal  disease  being  more  frequent  at  these  periods  of  life,  and  proving 
the  general  cause  of  death  after  the  operation. 

"  7.  That  in  patients  probably  and  palpably  the  subjects  of  vesical,  renal,  or 
other  organic  disease,  it  is  a  question  for  future  experience  to  decide  which  is 
the  best  operation  to  be  performed  for  the  relief  of  their  suffering ;  that  lithotomy 
recommends  itself  for  our  adoption  as  being  the  best  measure  for  the  relief  of 
the  patient  in  the  majority  of  cases;  although  evidence  apparently  tends  to 
show  that,  if  the  calculus  be  small,  it  may  be  successfully  removed  by  means  of 
the  lithotrite. 

"8.  That  there  is  an  intermediate  class  of  cases  between  the  absolutely  sound 
and  the  probably  or  positively  diseased,  in  which  no  operation  is  really  needed : 
including  those  in  which  there  is  evidence  of  organic  disease,  but  in  which  the 
calculus'causes  little  pain  or  constitutional  disturbance ;  and  in  which,  therefore, 
it  is  the  soundest  practice  to  apply  our  skill  simply  to  give  relief." 

This  paper  of  Mr.  Bryant  on  the  surgery  of  the  genito-urinary  system 
is  drawn  up  with  more  care  than  the  two  preceding  it  in  his  series,  but  it 
nevertheless  bears  too  many  marks  of  want  of  time,  or  of  carelessness. 
A  whole  chapter,  the  seventeenth,  is  not  accounted  for,  and  the  gTamnaar  is 
not  always  correct.  The  very  first  sentence  reads:  "In  previous  pages,  the 
surgery  of  the  Nervous,  Respiratory,  Circulatory,  and  Digestive  Systems 
have  received  our  attention:"  and  we  are  directed  on  page  172  not  to  have 
recourse  to  a  certain  operation  until  "all  other  local  and  constitutional 
treatment  have  been  tried  and  found  to  fail." 

X.  Case  of  Progressive  Atrophy  of  the  3IuscJes  of  the  Hands :  En- 
largement of  the  Ventricle  of  the  Cord  in  the  Cervical  Region,  with  Atro- 
phy of  the  Gray  Matter:  {Hydromyelus).    By  William  Gull,  M.  D. 

The  interest  of  this  case,  pathologically,  rests  in  the  fact  that,  from  the 
sudden  death  of  the  patient  from  typhus  fever,  an  opportunity  was  afforded 
of  discovering  the  "  progressive  muscular  atrophy"  to  have  had  a  central 
cause.  There  was  chronic  cervical  hydromyelus  comparable  to  a  chronic 
hydrocephalus.  The  distension  of  the  ventricle  of  the  cord,  by  an  accu- 
mulation of  fluid,  caused  atrophy  of  the  gray  matter  to  such  an  extent, 
that  in  certain  parts  of  the  cervical  region  no  other  remains  were  found 
but  the  anterior  cornua. 

The  history  of  the  case  must  also  suggest  some  doubts  as  to  the  truth 
of  the  present  theories  of  the  function  of  the  gray  matter  of  the  cord.  A 
very  large  part  was  here  slowly  removed  without  affecting  sensation  to  any 
corresponding  extent,  and  without  disturbing  the  general  functions  of  the 
cord,  or  the  influence  of  the  brain  on  the  parts  below. 

This  paper  is  illustrated  by  a  wood  cut  and  a  lithographic  plate. 

XI.  A  Case  of  Arrest  of  Development  of  the  Humerus.    By  John 

BlRKETT. 

In  this  case,  the  right  humerus  was  only  seven  inches  in  length,  while 
the  left  measured  thirteen.  The  diameter  of  both  bones,  as  well  as  could 
be  determined  by  external  examination,  was  the  same.  The  movements  of 
the  shorter  arm,  and  its  muscular  development,  were  as  perfect  as  those  of 
the  other.  About  two  inches  below  the  acromion  was  a  small  cicatrix, 
where  during  infancy  (the  patient  was  then  25  years  of  age)  an  abscess  had 
opened,  and  continued  discharging  for  some  time,  without,  however,  at  any 
time  allowing  any  bony  matter  to  escape. 

This  disease  of  childhood,  situated  at  the  junction  of  the  epiphysis  with 
the  shaft,  where,  according  to  the  experiments  of  Hales,  Duhamel,  Hunter, 


1863.]  ,  Guy's  Hospital  Reports. 


13Y 


and  others,  the  shafts  of  the  long  bones  increase  in  length  by  bony  deposit 
at  their  ends,  may  be  safely  alleged  as  the  cause  of  the  deformity. 

A  lithographic  plate  is  attached  to  this  paper,  exhibiting  the  arrest  of 
development  just  described. 

XII.  Case  illustrating  the  Arrest  of  Development  of  the  right  Humerus, 
after  an  Injury  received  in  Infancy.    By  Thomas  Bryant. 

In  this  case  the  right  humerus  was  five  inches  shorter  than  the  left, 
while  in  other  respects  its  development  was  quite  natural.  The  patient,  who 
was  30  years  of  age,  had,  when  only  a  few  months  old,  received  an  injury 
to  the  right  shoulder  from  a  fall ;  which  injury  was  not  followed  by  any 
suppuration,  but  by  an  arrest  of  the  growth  of  the  limb.  This  injury  must 
have  been  sufficient  to  prevent  the  subsequent  growth  and  development  of 
the  cartilaginous  layer,  placed  between  the  shaft  of  the  long  bones  and 
their  epiphyses,  from  the  growth  and  ossification  of  which  the  elongation 
of  the  long  bones  is  effected. 

The  arrest  of  development  in  this  case  of  Mr.  Bryant  is  likewise  exhi- 
bited in  a  lithographic  plate. 

XIII.  Description  of  a  remarkable  Enlargement  of  the  Nerves.  By 
Walter  Moxon,  M.  D. 

The  nerves,  in  this  case,  were  those  of  a  subject  already  partially  dis- 
sected when  the  peculiarity  was  remarked ;  the  body  of  a  female  who  died 
in  the  hospital  of  some  chest  affection.  None  but  negative  information 
could  be  obtained  regarding  the  phenomena  of  her  nervous  system  during 
life,  which  may  be  regretted,  inasmuch  as  it  is  supposed,  by  some,  that  the 
amount  of  will  the  nerves  can  conduct  varies  with  their  magnitude.  The 
nerves  of  this  subject  were  uniformly  increased  in  size  throughout  their  en- 
tire extent,  so  as  to  be  nearly  three  times  larger  than  usual.  The  average 
diameter  of  the  nerve-tubules  was  ^Jo^h  to  ^io^h  inch,  in  place  of  ¥ oV otn 

This  remarkable  enlargement  of  the  nerves  is  illustrated  by  a  plate  con- 
taining five  figures. 

XIY.  Description  of  some  new  Wax-Models  lately  added  to  the  Museum. 
By  the  Curator. 

The  models  here  described  are  those  of  a  disease  of  the  skin  produced 
by  post-mortem  examinations,  or  verruca  necrogenica ;  arsenical  erup- 
tion on  the  face ;  glanders  ;  melanotic  tumours  of  the  leg;  and  pathologi- 
cal models  of  the  heart,  and  of  the  other  viscera  in  cardiac  diseases. 

The  disease  of  the  skin  of  the  hands,  which  is  produced  by  the  constant 
irritation  from  the  acridity  of  the  morbid  fluids  of  the  dead  body,  is  one  we 
have  never  met  with  or  seen  described  before.  A  warty  thickening  of  the 
epithelium  is  said  to  take  place,  in  these  persons,  on  the  knuckles  and  the 
first  joints  of  the  fingers.  This,  in  the  course  of  time,  becomes  of  a  dark 
colour,  and  fissured,  until  a  kind  of  ichthyotic  condition  is  produced. 

XV.  Some  Points  in  the  Toxicology  of  Copper.  By  William  Odling, 
M.  B.,  F.  R.  S. 

This  paper  contains  much  that  is  valuable  to  those  who  may  be  called 
'  upon  to  examine  organic  tissues  for  the  presence  of  copper. 

XVI.  On  the  Nomenclature  of  Organic  Compounds.  By  William 
Odling,  M.  B.,  F.  K  S. 

In  this  paper  a  new  plan  of  nomenclature  in  organic  chemistry  is  advo- 


138 


Reviews. 


[Jan. 


cated,  on  account  of  the  striking  inconveniences  and  incongruities  of  the 
one  now  in  general  use. 

XYIL  Case  of  Deformity  of  the  Mouth,  after  Sloughing  of  the  Cheek 
from  Fever;  Operation  and  Recovery.    By  Thomas  Bryant, 

For  the  comprehension  of  the  deformity  that  existed  in  this  case,  the  na- 
ture of  the  operations  which  were  performed,  and  the  very  gratifying  result 
that  was  obtained,  it  is  necessary  to  consult  the  plates,  three  in  number,  by 
which  the  paper  is  illustrated.  It  is  one  of  the  most  satisfactory  cases  of 
the  kind  to  be  met  with  on  record. 

XYIII.  Almond  Food  as  a  Substitute  for  Bread  in  Diabetes.  By  F. 
W.  Pavy,  M.  D. 

In  the  treatment  of  diabetes,  almost  all  physicians,  whatever  views  they 
may  hold  respecting  the  pathology  of  the  disease,  agree  in  recommending 
abstinence  from  starchy  and  saccharine  articles  of  food.  An  exclusive 
diet  of  animal  food  is,  however,  so  fatiguing  to  the  patient,  that  it  is  a 
matter  of  importance  to  discover  a  vegetable  product,  containing  neither 
sugar  nor  starch,  that  may  be  used  as  a  substitute  for  bread.  In  searching 
for  such  a  substitute,  medical  men  have  confined  themselves  to  separating 
the  starch  from  the  gluten  and  lignin  of  the  seeds  of  the  cerealia.  Mr. 
Pavy  has  turned  his  attention  to  the  seeds  where,  in  place  of  starch,  oil  is 
found,  and  after  passing  in  review  many  vegetable  products,  has  fixed  upon 
the  sweet  almond  as  the  most  promising.  These,  when  thoroughly  ground, 
,  he  finds  to  be  readily  digested,  and  the  oleaginous  element  is  desirable  as  an 
article  of  consumption  in  diabetic  patients,  who  are  unable  to  use  the  other, 
the  saccharine,  form  of  the  calorifacient  element  of  food. 

Three  cases  are  reported,  showing  the  effect  of  the  almond  food,  con- 
joined with  an  animal  diet,  in  diminishing  the  elimination  of  sugar. 

XIX.  On  the  Water  of  Guy's  Hospital  Well.  By  August  Dupre, 
PH.  D.,F.  C.  S. 

This  paper  contains  nothing  of  special  interest  to  our  readers. 

XX.  Spontaneous  Aneurism  of  the  Brachial  Artery  cured  by  Compres- 
sion.   By  John  Birkett. 

The  patient,  in  this  case,  was  a  medical  man,  only  29  years  of  age,  who 
could  not  remember  to  have  ever  received  any  blow,  strain,  or  injury  of  any 
kind,  on  the  arm.  The  compression  was  continued  for  more  than  four 
months.  W.  F.  A. 


j 


1863.] 


139 


BIBLIOGRAPHICAL  NOTICES. 

Art.  XX. — Transactions  of  State  Medical  Societies: — 

1.  Medical  Communications  of  the  Massachusetts  Medical  Society,  at  its 

Annual  Meeting,  held  May,  1862.  8vo.  pp.  216,  second  series,  Vol.  VI., 
Part  II.    Boston,  1862. 

2.  Medical  Communications  with  the  Proceedings  of  the  Seventh  Annual 

Convention  of  the  Connecticut  Medical  Society,  held  at  Bridgeport, 
May  28  and  29,  1862.    New  series,  Vol.  I.,  No.  3.    New  Haven,  1862. 

The  initial  paper  in  the  present  volume  of  communications  made  to  the  Mas- 
sachusetts Medical  Society — on  the  topographical  distribution  and  local  origin 
of  consumption  in  Massachusetts — is  from  Dr.  Henry  I.  Bowditch,  of  Boston. 
It  is,  confessedly,  one  of  a  deeply  interesting  character,  and  well  deserving 
of  a  careful  examination  by  every  member  of  the  profession.  The  truth 
of  the  two  propositions  laid  down  by  the  author,  so  far  as  the  facts  collected 
and  arranged  by  him  in  the  paper  before  us  go,  would  seem  to  be  established  as 
to  Massachusetts  and  the  New  England  States  generally.  Should  they  be  found 
to  hold  good  in  respect  also  to  the  other  habitable  portions  of  the  globe,  the 
communication  of  Dr.  Bowditch  cannot  but  be  viewed  as  one  of  the  most  im- 
portant of  the  recent  contributions  to  pathology. 

The  propositions  discussed  by  Dr.  Bowditch  are  as  follows : — • 

"First.  A  residence  on  or  near  a  damp  soil,  whether  that  dampness  be  inhe- 
rent in  the  soil  itself,  or  caused  by  percolation  from  adjacent  ponds,  rivers,  mea- 
dows, marshes,  or  springy  soils,  is  one  of  the  primal  causes  of  consumption." 

"Second.  Consumption  can  be  checked  in  its  career,  and  possibly,  nay  pro- 
bably, prevented  in  some  instances,  by  attention  to  this  law." 

The  evident  increase  in  the  prevalence  of  consumption  throughout  the  greater 
portion  of  the  United  States,  and  the  almost  invariable  destruction  of  life  by 
which  it  is  attended,  renders  everything  which  relates  to  the  causes  by  which  it 
is  produced  of  the  highest  importance,  inasmuch  as  a  knowledge  of  its  primary 
causes  constitutes  the  only  sure  basis  upon  which  a  rational  and  certain  pro- 
phylaxis of  the  disease  is  to  be  founded. 

The  etiology  of  pulmonary  phthisis  has  heretofore  proved  a  stumbling  block 
in  the  way  of  every  pathologist  who  has  undertaken  the  investigation  of  the 
disease.  Much  of  this,  it  appears  to  us,  has  arisen,  in  part,  from  imperfect 
observation  in  respect  to  the  circumstances  under  which  the  disease  has  been 
found  to  prevail,  and  to  the  greatest  extent ;  in  part,  also,  from  not  properly 
distinguishing  between  the  tubercular  dyscrasy,  and  the  diseases  which  occur 
in  those  individuals  in  whom  such  dyscrasy  is  present ;  the  causes  to  which 
the  one  or  the  other  owes  its  origin,  and  the  phenomena  and  results  proper  to 
them  respectively. 

By  whatever  causes  engendered,  it  is  very  evident  that  tuberculosis  is  a  vice 
of  nutrition.  Cells,  it  is  true,  are  regularly  formed  from  the  blood,  but  of  such 
a  character  as  to  unfit  them  from  undergoing  the  metamorphosis  required  to 
assimilate  them  with  the  tissues,  for  the  building  up  or  renewal  of  which  they 
were  destined.  They  remain,  therefore,  in  the  tissues  as  albuminoid  deposits. 
These  accumulate,  more  or  less  slowly,  interfering  by  their  presence  and  bulk 
with  the  functions  of  the  organ  in  which  they  are  present,  and,  undergoing  a 
slow  process  of  softening,  bring  about,  finally,  its  entire  destruction. 

The  course  of  tuberculosis  is  materially  modified,  when,  from  any  cause,  in- 
flammation is  excited  in  the  organs  which  are  its  seat.  Thus,  in  cases  of  simple 
tuberculosis  of  the  lungs,  we  have  a  form  of  consumption,  insidious  in  its  ap- 
proach, and  progressing  slowly  towards  a  fatal  termination — a  true  phthisis 


uo 


Bibliographical  Notices. 


[Jan. 


puJmonalis — a  gradual  wasting,  a  melting  away,  as  it  were,  of  the  lungs  and  of 
the  entire  body;  where  death  would  seem  to  linger,  as  though  loth  to  desert  the 
emaciated  frame.  When,  however,  inflammation  is  set  up  in  the  tuber culized 
lung,  we  have  then  our  more  common  form  of  consumption ;  which  is  often,  ap- 
parently, sudden  in  its  development,  and  always  more  or  less  rapid  in  its  fatal 
course,  sometimes  so  much  so  as  to  obtain  for  it  the  popular  denomination  of 
galloping  consumption. 

Extended  series  of  statistics  bearing  upon  the  subject  of  the  climatology  of 
consumption,  collected  under  circumstances  well  adapted  to  insure  their  entire 
accuracy,  would  appear  to  prove  that  the  climate  the  least  favourable  to  the 
production  of  tuberculosis,  and  especially  of  the  lungs,  is  one  that  is  dry,  equa- 
ble, and  of  a  low  rather  than  a  high  temperature. 

We  collected,  some  few  years  since,  a  very  large  number  of  statistics  to  illus- 
trate the  particular  circumstances  under  which  consumption  was  found  most 
extensively  to  prevail,  and  the  class  of  persons  who  constitute  the  majority  of 
its  victims.  From  a  careful  collation  of  these,  we  arrived  at  the  conclusion  that 
an  indoor,  sedentary,  luxurious,  and  artificial  life  was  the  one  by  which  most 
frequently  consumption  was  engendered ;  while,  on  the  other  hand,  an  active 
life,  spent  chiefly  in  the  open  air,  in  healthy  situations,  followed  by  an  adequate 
amount  of  sleep  at  night,  in  dry,  clean,  and  well  ventilated  chambers,  with  a 
sufficient  supply  of  appropriate  nourishment  and  clothing,  constituted  the  con- 
ditions which  would  most  certainly  guarantee  against  its  occurrence. 

The  fact  which  has  been  lately  established,  that  a  very  large  number,  if  not 
the  majority  of  the  sailors  belonging  to  the  national  marine  of  Great  Britain,  who 
die  of  disease,  perish  from  tubercular  consumption,  would  appear,  at  first  sight, 
to  invalidate  the  correctness  of  the  above  conclusion,  but  we  believe  it  will  be 
found  to  do  so  only  in  appearance  when  all  the  circumstances  under  which  sailors, 
even  those  on  board  government  vessels,  are  placed,  are  closely  investigated. 
But,  let  this  be  as  it  may,  it  is  unquestionably  true — basing  our  conclusion  upon 
the  whole  of  the  facts  in  our  possession — that  they  who  inhabit  a  dry,  cool, 
equable  climate,  lead  an  active  outdoor  life,  with  sufficient  intervals  of  rest,  and 
are,  at  the  same  time,  amply  supplied  with  proper  food  and  raiment,  are  those 
in  whom  consumption  has  been  found  to  be,  to  say  the  least,  a  very  rare  disease. 

In  the  communication  which  has  suggested  these  remarks,  Dr.  Bowditch  has 
adduced  a  chain  of  evidence  which  he  believes  will  fully  establish  the  fact  that 
soil  moisture  constitutes  one  of  the  prime  causes  of  consumption,  at  least  in  the 
New  England  States,  and  perhaps,  also,  in  all  other  places  where  the  disease 
prevails. 

The  axioms  which  Dr.  B.  lays  down  are  these : — 

"1st.  Consumption  is  not,  as  some  writers  have  contended,  endemic  equally 
in  every  part  of  New  England ;  but  there  are  some  localities  where  it  is  very 
rife,  and  others  where  it  is  vastly  less  destructive  than  in  the  State  at  large. 

"  2d.  There  is  a  law,  hitherto  scarcely  noticed,  or  but  vaguely  hinted  at  by 
one  or  two  individual  writers,  but,  as  I  believe,  never  proved  until  now,  which 
is  one  of  the  main  causes,  if  not  the  sole  cause,  of  this  unequal  topographical 
distribution  of  consumption  in  New  England. 

"  3d.  This  law  is  intimately  connected  with,  and  apparently  dependent  on, 
the  humidity  of  the  soils,  on  or  near  which  stand  the  towns,  villages,  or  even 
single  houses,  where  consumption  prevails." 

The  existence  of  this  law  of  soil  moisture,  as  one  of  the  prime  causes  of  con- 
sumption in  New  England,  can  be  proved,  Dr.  B.  thinks,  by  several  lines  of 
argument,  resting  on  actual  facts  obtained  either  from  public  or  private  records, 
statistical  data,  or  the  opinions  of  physicians  practising  medicine  in  various 
parts  of  New  England.  These  lines  of  proof,  or  of  argument,  are  drawn  from 
the  following  sources: — 

L  Massachusetts  State  Registration  Reports. 

II.  Returns  made  to  Dr.  B.  as  a  committee  of  the  State  Society,  in  the  form 
of  written  reports  from  resident  physicians,  of  one  hundred  and  eighty-three 
towns. 

III.  Actual  statistics  of  deaths  from  consumption  furnished  by  the  same  cor- 
respondents.   Some  of  these  statistics  are  but  incidentally  mentioned,  while 


1863.]  Transactions  of  State  Medical  Societies.  141 

others  are  from  towns  districted  and  carefully  examined  with  reference  to  the 
relative  prevalence  of  consumption  in  the  different  districts.  In  some  of  the 
most  important  of  these,  the  examination  was  made,  Dr.  B.  states,  without  his 
correspondent  or  himself  being  aware  of  the  existence  of  any  law  such  as  that 
which  he  presents. 

"IV.  Peculiarities  of  certain  towns,  and  of  villages  in  the  same  townships,  in 
some  of  which  consumption  is  quite  prevalent,  and  in  others  mucb  less  so ;  these 
differences  being  connected  most  closely  with  corresponding  differences  in  the. 
amount  of  moisture  of  the  soil  of  said  places. 

"V.  Certain  well  known  houses,  which,  in  various  towns,  are  known  by  the 
inhabitants  and  physicians  to  have  been  long  noted  as  the  abode  of  consump- 
tion, and  in  some  of  which  several  families  have  been,  during  the  past  fifty  years, 
cut  off  by  the  disease,  without  the  least  suspicion,  on  the  part  of  the  occupants, 
of  the  fatal  position  in  which  the  houses  were  placed. 

"VI.  Confirmatory  facts,  statistics,  and  opinions,  from  Ehode  Island,  Maine, 
and  New  Hampshire. 

"VII.  The  medical  statistics  given  in  the  Eeport  on  the  health  of  the  United 
States  Army,  strongly  supporting  the  idea  of  the  existence  of  the  same  law,  and 
the  operation  of  it  over  the  whole  of  the  United  States. 

"VIII.  Eesults  of  Dr.  B.'s  own  practice  since  he  first  became  convinced  of 
the  truth  of  the  law — said  results  consisting  of  (a)  statistics  from  his  private 
medical  records :  (b)  Eesults  actually  derived  from  his  choice  of  localities  for 
consumptive  patients,  based  on  a  belief  in  the  law." 

So  far  as  the  evidence  goes  which  is  derived  from  these  several  sources,  and 
very  fully  and  fairly  set  out  in  the  report  before  us,  it  would  seem  very  certainly 
to  establish  the  following  general  propositions,  namely,  that  consumption  is  not 
equally  distributed  over  New  England;  that  its  greater  or  less  prevalence  de- 
pends very  much  upon  the  characteristics  of  the  soil,  on  or  near  which  the 
patients  affected  with  it  have  resided ;  and  that  moisture  of  the  soil  is  the  only 
known  characteristic  that,  so  far  as  our  present  investigations  have  gone,  is 
connected  with  the  consumption  breeding  districts.  ■ 

Among  the  important  practical  questions  and  suggestions  which  naturally 
arise  from  the  subject  as  presented  by  Dr.  Bowditch,  are  the  following,  which 
we  quote  entire  : — 

"Are  there  any  localities  in  New  England,  which,  from  these  investigations, 
we  should  deem  unfitted  for  the  residence  of  consumptive  patients  ? 

"I  believe,"  says  Dr.  B.,  "that  all  towns,  parts  of  towns,  houses  even,  that 
rest  on  damp,  cold  soils,  are  by  that  very  fact  peculiarly  liable  to  the  prevalence 
of  consumption.  I  believe  that  similar  locations  near  wet  meadows,  rivers, 
marshes,  &c,  though  less  subject  to  the  law,  are  nevertheless,  in  a  lesser  degree, 
promoters  of  consumption  in  the  families  resident  thereupon.  Even  hills  with 
a  clayey  subsoil  retaining  moisture,  though  not  absolutely  evil,  are  less  good 
than  a  perfectly  dry,  porous  soil,  removed  from  any  moisture.  I  suspect,  more- 
over, that  we  ought  to  inquire  more  particularly  than  we  have  heretofore  done, 
as  to  the  exact  condition  of  the  cellar  of  a  residence,  whether  it  be  wet  or  dry, 
even  when  the  surroundings  of  the  residence  may  seem  perfectly  good.  All 
these  statements  I  make,  not  on  theory  alone,  but  from  actual  experience,  I 
think,  of  their  truth,  as  learned  from  my  professional  practice  during  the  past 
four  or  five  years.  Again,  on  theoretical,  but  I  believe  just  grounds,  I  have 
objected  to  allowing  consumptive  patients  to  reside  in  houses,  heavily  and 
closely  shaded  by  trees  and  vines  ;  because  the  rays  of  the  sun  being  prevented 
from  reaching  such  abodes,  dampness  and  extra  coolness  are  thereby  promoted. 
*  *  *  Following  out  this  idea,  I  have,  at  times,  thinned  out  trees  around  a 
residence  where  a  family  was  growing  up,  and  among  which  one  member  had 
already  shown  signs  of  tubercular  disease." 

The  next  question  which  suggests  itself  is :  Are  there  not  places  a  residence  in 
which,  according  to  the  investigations  before  us,  will  tend  to  prevent  phthisis, 
or,  at  least,  in  which  consumption  will  prevail  much  less  than  elsewhere,  or  pos- 
sibly not  at  all  ? 

"I  do  not  absolutely  know,"  Dr.  B.  remarks,  "a  single  spot  in  New  England, 
where  consumption  can  be  said,  by  statistics,  never  to  have  occurred.  In  choos- 


142  Bibliographical  Notices.  [Jan. 

ing  a  site  for  a  dwelling  house,  the  great  desideratum  is  to  obtain,  not  a  perfectly 
arid  place,  for  no  such  spot  could  be  inhabited  by  man,  but  it  should  be  in  a 
portion  of  the  township  which  is  neither  so  high  as  to  be  exposed  to  violent 
gusts  of  weather,  nor  so  low  that  moisture  will  collect  around  it.  Let  it  be  on 
the  side  of  a  hill,  or  plain,  open  to  the  south,  and,  if  possible,  defended  from  the 
north  and  east,  on  a  dry,  porous  soil,  through  which  water  freely  percolates,  and 
which,  even  after  a  rain,  retains  little  moisture.  Let  the  cellar  be  dry,  in  which 
no  mould  will  collect.  Such  a  situation,  I  believe,  on  theory  (confirmed  by  my 
general  experience),  if  it  can  be  found  in  any  town  in  New  England,  will  be  more 
favourable  for  the  consumptive,  and  less  likely  to  have  consumption  appear  in 
it,  than  another  spot,  with  a  different  exposure,  and  having  a  wet  soil." 

A  third  question  presents  itself :  Which  are  the  places  which  experience  has 
shown  to  be  the  best  for  the  residence  of  consumptives  ? 

"There  are  two  distinct  classes  of  townships  and  localities,"  says  Dr.  B., 
"which  I  should  place  in  this  category.  They  are  either  inland  towns  or 
islands,  eight  or  ten  miles  from  the  shore,  and  thereby  being,  in  reality,  under 
an  oceanic  climate.  Doubtless,  there  are  many  more  localities,  besides  those  I 
shall  name,  scattered  in  almost  all  the  inland  portions  of  the  New  England 
States.  These  must  be  eventually  discovered  by  the  registration  agents,  or  by 
the  careful  and  conscientious  investigations  of  resident  physicians.  I  have  had 
actual  experience  of  the  advantages  of  placing  patients  at  Grantville,  a  district 
in  the  township  of  Needham ;  also,  upon  the  drier  portions  of  Sharon  and  of 
Canton,  and  at  the  Isles  of  Shoals.  All  these  towns  lie  about  ten  or  fifteen  miles 
inland,  while  the  islands  are  about  the  same  distance  from  the  coast.  The  former 
have  the  land ;  the  other  the  oceanic  climate  influences.  The  townships  are 
remarkable  for  the  dryness  of  their  soil,  and  are  generally  somewhat  elevated. 
In  every  one  of  them,  I  have  had  patients  improve  greatly,  and  some,  whom  I 
believe  would  have  died  in  low  coast  or  wet  inland  spots,  have  recovered  or 
speedily  improved  from  serious  symptoms.  The  patients  have  all  described  a 
decided  and  peculiar  effect,  as  having  been  produced  on  their  lungs  by  the 
atmosphere  of  these  places,  whereby  they  were  enabled  to  breathe  more  easily. 

"The  Isles  of  Shoals  are  off  Portsmouth,  New  Hampshire.  From  the  reports 
of  physicians  I  have  little  doubt  that  Nantucket,  Martha's  Vineyard,  and  pos- 
sibly Block  Island,  lying  south  of  Massachusetts  and  Rhode  Island,  must  be 
likewise  useful.  I  am  also  inclined  to  believe  that  Nahant  and  Winthrop,  rocky 
promontories  projecting  from  the  coast,  will  prove  favourable  sites. 

"It  may  be  objected,  that  in  suggesting  an  island,  I  virtually  ignore  all  my 
previous  statements,  in  regard  to  the  influence  of  moisture,  as  a  cause  of  con- 
sumption. I  answer,  1st.  That  it  is  evident  that  a  small  island,  with  an  oceanic 
climate,  may,  and  probably  would,  produce  very  different  effects  on  a  patient 
from  those  caused  by  a  place  on  low  and  damp  land.  Hence,  the  two  places  are 
evidently  under  wholly  different  influences.  The  two  spots  are  not  analogous. 
But  2d.  In  the  places  I  have  named,  I,  in  reality,  do  not  vary  from  the  rule 
of  dryness  of  the  soil,  for  all  of  them  are  either  mere  rocks,  rising  out  of  the 
ocean,  with  no  marshes  near;  or  they  are  masses  of  sand,  so  to  speak,  and 
essentially  dry  of  character.  Hence,  they  do,  in  reality,  fall  within  the  rule — 
only  they  have  the  oceanic  atmosphere  instead  of  the  land  atmosphere,  encircling 
and  covering  them. 

"  Whether  this  is  really  a  correct  explanation  or  not,  I  am  certain  that,  in 
many  cases  of  early  phthisis,  the  tonic,  clear,  soft  air  of  the  Isles  of  Shoals,  in 
summer,  has  been  of  immense  service.  Two  patients  spent  the  winter  there.  In 
one  patient,  a  crackling  throughout  the  whole  of  one  breast  disappeared,  which 
I  fear  it  would  not  have  done  had  the  patient  remained  in  Boston.  The  winds 
were  violent,  but  the  temperature  was  less  severe  than  in  corresponding  places 
on  the  shore.  These  winds  will,  however,  always  prevent  many  from  residing  at 
the  shoals  during  the  winter,  unless,  perchance,  the  inherent  healthfulness  of  the 
situation,  and  the  superb  marine  views,  that  one  can  enjoy  there,  should,  in 
some  future  time,  cause  a  Sanatarium  to  be  erected,  properly  constructed,  to 
obviate,  at  least  in  part,  these  difficulties." 

The  subject  of  Dr.  Bowditch's  communication  is  of  too  great  importance,  and 
drawn  up  with  too  much  care,  not  to  demand  for  it  a  careful  and  candid  perusal 


< 


1863.]  Transactions  of  State  Medical  Societies.  143 

on  the  part  of  every  medical  man.  If  the  profession  generally  were  to  turn  their 
attention  to  an  investigation  of  the  influence  of  a  dry  or  wet  soil  on  the  produc- 
tion or  prevention  of  consumption,  a  mass  of  facts  would  be  soon  accumulated 
of  incalculable  value  in  directing  to  a  rational  treatment  of  the  disease. 

After  a  list  of  diseased  members  of  the  Society,  and  a  series  of  obituary  no- 
tices, follows  a  communication  from  Dr.  A.  Euppaner,  of  Boston,  on  the  subject 
of  hypodermic  injections  in  the  treatment  of  neuralgic  and  other  diseases  of  the 
nervous  system. 

Hypodermic  injection,  or  the  application  of  opiates  to  the  immediate  peri- 
pheral seat  of  the  pain  in  cases  of  neuralgic  suffering,  has  recently  attracted 
considerable  attention  on  the  part  of  several  of  the  British  physicians,  and  of  a 
few  upon  the  continent  of  Europe.  Of  the  effects  of  the  treatment  some  of  these 
gentlemen  speak  in  the  highest  terms  of  commendation.  Patients,  they  state, 
who  had  suffered  for  days  and  nights  extreme  agony  from  an  attack  of  neuralgia, 
notwithstanding  the  use  of  large  doses  of  morphia,  have  been  known  to  sink  into 
a  state  of  calm  repose  within  a  few  minutes  after  a  resort  to  hypodermic  injec- 
tions. Besides  the  list  of  cases  of  neuralgia  relieved  by  this  plan  of  medication, 
the  records  of  our  profession  present  the  history,  also,  of  cases  of  paralysis, 
tetanus,  delirium  tremens,  chorea,  continued  watchfulness,  etc.,  which  are  re- 
ported as  having  been  successfully  treated  by  the  hypodermic  method. 

In  the  communication  of  Dr.  Ruppaner  the  following  are  the  questions  dis- 
cussed :  1st.  The  requisites  for  obtaining  satisfactory  and  safe  results  from  the 
use  of  hypodermic  medication.  2d.  The  advantages  obtained  by  the  treatment. 
3d.  Its  disadvantages.  These  are  followed  by  the  history  of  210  cases,  treated 
by  hypodermic  injections,  reported  by  eighteen  physicians  and  surgeons. 

As  requisites  for  obtaining  satisfactory  and  safe  results,  Dr.  R.  enumerates 
the  following :  a.  That  the  case  be  a  proper  one.  b.  That  a  suitable  instrument 
be  employed,  c.  That  a  concentrated  solution  of  the  remedy  injected  be  used. 
d.  That  the  quantity  of  fluid  injected  be  exactly  determined  and  known,  e. 
That  a  proper  place  be  chosen  for  the  injection;  and  that  it  be  not  repeated  at 
short  intervals  at  the  same  point. 

As  to  the  cases  most  proper  for  treatment,  Dr.  R.  remarks : — 

"  As  a  general  rule,  it  will  be  found  that  the  curative  effect  of  the  operation 
is  most  manifest  in  uncomplicated  cases  of  recent  standing,  and  in  those  which 
are  most  benefited  by  morphia  applied  to  the  blistered  surface.  Hence,  to  test 
the  value  of  the  proposed  method  of  relieving  the  pain,  it  is  essential  that  the 
application  in  neuralgia  be  limited  to  purely  neuralgic  affections — where  the  pain 
is  actually  seated  in  the  course  of  the  nerve ;  and  it  must,  moreover,  be  remem- 
bered, that  agreeably  to  the  laws  by  which  nervous  action  is  propagated,  the 
irritation,  that  is,  the  pain,  maybe  seated  directly  on,  or  reflected  indirectly  on 
the  nerve,  at  any  point  between  its  extreme  peripheral  distribution  and  the  point 
at  which  it  joins  the  brain." 

"If  the  patient  be  subject  to  rheumatism  or  gout,  or  infected  with  a  syphilitic 
taint,  or  is  suffering  from  gastric  and  intestinal  irritation,  or  exhibit  symptoms 
of  disease  of  the  brain,  or  if  we  suspect  pressure  upon  the  nerve  itself,  caused 
either  by  a  tumour  or  by  thickening  of  the  bony  canal  through  which  a  branch 
of  a  nerve  passes,  we  cannot  expect  success  from  subcutaneous  injections,  ex- 
cept temporarily — unless  we  use,  at  the  same  time,  constitutional  remedies  ap- 
propriate to  the  case.  In  so  far  as  this  can  be  done,  subcutaneous  injection, 
with  judicious  constitutional  treatment,  will  seldom  disappoint  the  practitioner." 

The  operation  should  not  be  performed  when  heart  disease  exists,  nor  where 
there  is  great  debility,  nor  in  the  very  aged. 

In  respect  to  the  proper  instrument  to  be  employed,  Dr.  R.  prefers  a  screw 
syringe,  giving  the  exact  number  of  minims  used.  To  the  body  of  the  syringe 
hollow  needles  of  various  lengths  are  attached.  The  point  of  the  needle  is 
sharp,  and  perforated  on  one  side  by  an  oblique  opening,  through  which  the  fluid 
to  be  injected  is  expelled.  The  finer  the  needle  the  better,  as  there  will  be  then 
less  loss  of  blood  at  the  time,  and  less  oozing  afterwards. 

Needles  of  tempered  steel  answer  every  purpose.  In  using  the  instrument,  a 
fold  of  the  skin  is  to  be  held  with  the  left  index-finger  and  thumb,  so  as  to  make 
the  part  beyond  the  fingers  tense,  through  which  the  point  of  the  needle,  held 


144 


Bibliographical  Notices. 


[Jan. 


at  a  right  angle  with  the  part,  is  to  be  pressed,  with  a  quick,  steady  movement, 
and  then  given  such  a  direction  as  shall  be  esteemed  best.  The  injection  of  the 
requisite  amount  of  fluid  having  been  effected,  and  the  syringe  withdrawn,  the 
escape  of  the  injection  is  to  be  prevented  by  pressure  for  a  moment  upon  the 
puncture  with  the  thumb.    No  adhesive  plaster  should  be  applied. 

As  it  is  important  not  to  inject  a  large  quantity  of  fluid  lest  undue  disturb- 
ance of  the  cellular  tissue  be  produced,  a  concentrated  solution  of  the  seda- 
tive should  always  be  used  for  injecting.  It  is  evident  that  the  stronger  is  the 
solution  we  employ,  the  fewer  number  of  drops  is  requisite  to  accomplish  the 
desired  result. 

Our  object  being  to  procure  a  certain  effect  with  as  small  quantity  as  possible 
of  fluid,  we  should  duly  consider  and  accurately  determine  the  dose  of  the  article 
injected.  There  should  always  be  an  adequate  effect  produced,  still  there  is 
danger  in  producing  too  great  an  impression.  It  is  impossible  to  lay  down  any 
general  rule  as  to  the  amount  it  is  proper  to  inject.  The  history  of  each  case 
must  be  our  guide — age  and  sex,  experience,  and  the  results  of  tentative  ex- 
periences being,  also,  taken  into  account.  Dr.  R.  offers,  the  following  summary 
as  deserving  of  attention  : — 

1-2.  Chronic  cases  require  a  larger  dose ;  while  the  dose  for  females  ought 
to  be  smaller  than  that  for  males. 

"  3.  First  injections  ought  always  to  be  smaller  than  subsequent  ones,  for  the 
sake  of  safety.  As  a  general  rule,  half  the  ordinary  stomachic  dose  for  males, 
and  the  third  for  females,  ought  to  be  used. 

"4.  If  the  injection  has  to  be  repeated,  the  quantity  can  easily  be  increased. 
In  such  cases,  sufficient  time  must  be  allowed  to  elapse  for  the  effect  of  the  first 
injection  to  pass  off  before  the  second  is  given.  In  174  cases,  reported  by  18 
different  physicians,  where  the  exact  quantity  injected  has  been  stated,  the  first 
injections  for  adult  females  vary  from  £  to  £  of  a  grain  of  morphia  dissolved  in 
a  few  drops  of  water ;  for  adult  males,  from  £  to  -|-  or  §  of  a  grain  of  the  same. 
My  average  minimum  dose  for  females  is  £  of  a  grain,  and  \  of  a  grain  for 
males. 

"  5.  In  delirium  tremens,  mania,  tetanus,  and  paralysis,  the  quantity  first  in- 
jected may  be  more  powerful  than  in  cases  of  neuralgia.  Large  doses  of  nar- 
cotics may  be  injected  with  perfect  safety  in  proper  cases.  Thus,  in  a  case  of 
traumatic  tetanus,  under  the  care  of  Dr.  W.  Read,  of  Boston,  I  injected  two  grains 
of  acetate  of  morphia  in  four  operations,  one  directly  after  the  other,  without  any 
ill  effects.  Dr.  Behier,  of  France,  reports  having  used  61£  minims  of  a  solution 
of  sulphate  of  strychnia,  in  several  cases  of  paralysis,  in  one  injection,  and  to 
have  repeated  the  operation  six  times.  In  fact,  we  are  hardly  as  yet  aware  to 
what  extent  this  treatment  may  be  carried ;  further  experiments  are  required  to 
lay  down  safe  and  reliable  rules." 

According  to  Dr.  R.,  the  injection  in  cases  of  neuralgia  should  always  be  made 
at  the  most  painful  part,  which  can  be  easily  ascertained  by  pressure  upon  the 
nerve.  By  this  procedure  almost  immediate  relief  will,  in  many  cases,  be  ob- 
tained ;  otherwise,  several  minutes,  often  a  much  longer  period,  as  well  as  a 
larger  quantity  of  the  narcotic  is  required  to  produce  the  desired  effect. 

In  other  cases  than  those  of  neuralgia,  in  which  subcutaneous  injections  have 
been  found  beneficial,  localization  is  not  a  necessary  condition  to  the  success  of 
the  operation.  In  reference  to  the  wide  applicability  of  this  form  of  medication, 
Dr.  R.  remarks  : — 

"  When  all  other  measures  have  been  tried  and  failed,  as  is  but  too  often  the 
case,  to  bring  sleep  to  the  restless  patient,  harassed  by  excruciating  pain; 
when  the  delirious  or  the  maniac  actually  defies  all  restraints  put  into  service  ; 
when  tetanic  spasms  exclude  the  possibility  of  introducing  medicines  into 
the  stomach ;  when  that  member  itself  refuses  any  longer  to  perform  its  ac- 
customed duties ;  when  rheumatic  pain  constantly  shifts  from  place  to  place ; 
in  surgical  injuries ;  in  puerperal  peritonitis ;  in  short,  in  all  those  affections 
where  the  nervous  system  at  large  is  affected,  where  the  pain  is  more  or  less 
general,  the  hypodermic  injection  of  narcotics  has  been  tried,  and  in  all  cases 
the  effect  was  immediate,  or  nearly  so,  either  quiet  or  sleep  sooner  or  later  super- 
vening." 


1863.] 


Transactions  of  State  Medical  Societies. 


145 


The  advantages  of  this  plan  of  medication,  according  to  Dr.  E.  are,  (a.)  The 
painlessness  of  its  application,  (b.)  The  speedinesss  of  its  action,  compared 
with  the  action  of  remedies  however  otherwise  administered,  (c.)  Its  certainty  of 
action  when  all  other  means  have  been  exhausted  or  rendered  useless,  (d.)  The 
accuracy  with  which  the  amount  injected  can  be  known,  enabling  us  thus  to  ob- 
tain the  whole  effect  of  the  known  quantity  introduced,  (e.)  The  greater  bene- 
fit exerted  on  the  local  affection,  by  bringing  the  medicinal  agent  in  direct 
contact  with  the  parts  involved  in  the  disease. 

The  disadvantages  by  which  the  treatment  is  sometimes  attended,  are  thus 
summed  up  by  Dr.  R. :  (a.)  The  power  of  the  remedy,  and  consequently  the 
danger  of  its  being  used  indiscriminately,  (b.)  The  possibility  of  local  inflam- 
mation occurring  in  the  part  repeatedly  punctured,  (c.)  The  nausea  and  vomit- 
ing sometimes  induced,  (d.)  The  possibility  of  the  escape  of  the  injected  fluid 
through  the  puncture  made  for  its  introduction,  (e.)  The  pain  occasioned  by  the 
introduction  in  some  positions  of  the  needle.  All  of  these  alleged  disadvantages, 
Dr.  R.  insists,  can  be  overcome  by  the  proper,  careful,  and  skilful  management 
of  the  operation. 

In  proof  of  the  value  and  general  efficacy  of  hypodermic  medication,  Dr.  R. 
has  collected  from  the  most  reliable  English,  French,  German,  and  American 
sources  210  cases,  reported  by  eighteen  observers,  in  which  it  was  employed. 
Forty-eight  of  these  cases  were  of  those  treated  by  himself. 

Of  these  cases  129  were  of  neuralgia,  and  81,  including  21  of  which  the  reports 
are  deficient  in  some  particulars,  were  of  general  nervous  disorders.  Of  the 
neuralgic  cases,  55  were  sciatic,  37  facial,  14  intercostal,  6  hemicrania,  5  lumbo- 
abdominal,  4  cervico-brachial,  3  of  upper  extremities,  1  cervico-occipital. 

Of  the  remaining  (81)  cases  of  general  nervous  disorders,  16  were  of  rheumatic 
muscular  pains ;  10  of  delirium  tremens ;  9  of  paralysis  (viz.,  5  paraplegia,  2 
hemiplegia,  1  of  lower  extremity,  1  of  deltoid) ;  4  of  tetanus  ;  4  of  pleurodynia ; 
3  of  chest  asthma ;  2  of  chorea ;  2  of  continued  wakefulness ;  1  of  pains  symp- 
tomatic of  cancer  uteri ;  1  of  mania  ;  1  of  puerperal  peritonitis  ;  1  of  sprain  ; 
1  of  dysuria ;  1  of  wound  of  the  eye ;  3  of  pains  dependent  on  other  affections ; 
cases  imperfect  in  particulars  21. 

Of  the  210  cases,  114  were  cured,  68  relieved,  8  not  relieved,  and  20  were  not 
heard  from.  Deduct  these  latter  and  we  have  190  cases  to  be  accounted  for, 
which  sum  up  as  follows : — 

"  Cured,  114  cases,  or  three-fifths  of  all  the  cases  reported. 

"Relieved,  68  cases,  or  a  fraction  over  one-third  of  the  whole  number  of  cases 
reported. 

"Not  relieved,  8  cases,  or  only  one  unsuccessful  case  in  every  24. 

" Or  to  recapitulate,  we  have  the  following  result:  Three  out  of  every  five 
patients  were  cured ;  that  is  to  say,  were  free  from  pain  and  discharged  weli,  at 
the  time  the  case  was  reported.  A  fraction  less  than  one  in  three  patients  was 
relieved  from  suffering  for  the  time.  One  out  of  every  24  patients  did  not  derive 
any  benefit  at  all  from  the  treatment." 

As  Dr.  R.  justly  remarks,  the  foregoing  result  is  strongly  in  favour  of  the 
operation.  Even  though  we  admit  that  many  of  the  cases  may  have  been  care- 
lessly reported,  and  were  simply  relieved  instead  of  being  cured,  the  evidence 
still  preponderates  in  favour  of  the  treatment. 

2.  The  initial  article  in  the  volume  of  communications  presented  at  the  an- 
nual convention  of  the  Connecticut  Medical  Society  for  1862,  is  the  address  of 
the  president.  Dr.  Josiah  Gr.  Beckwith.  The  subject  discussed  is  "Medical 
Progress."  The  address  is  highly  creditable  to  its  author — whether  it  be  con- 
sidered in  respect  to  the  truthfulness  and  appropriateness  of  the  sentiments  it 
inculcates,  as  to  the  aptness,  neatness,  and  beauty  of  the  language  in  which  these 
are  embodied.  The  views  it  inculcates,  are,  it  is  true,  by  no  means  new.  But, 
although  they  have  been  urged  upon  the  notice  of  the  profession  and  the  public 
again  and  again,  their  actual  importance,  and  proper  improvement  have,  here- 
tofore, been  almost  entirely  overlooked  and  neglected  by  both. 

This  address  is  followed  by  an  interesting  series  of  short  biographical  sketches, 
No.  LXXXIX.— Jan.  1863.  10 


146 


Bibliographical  Notices. 


commemorative  of  some  of  the  early  physicians  of  Norwich,  by  Dr.  A.  Wood- 
ward, of  Franklin. 

To  this  succeeds  an  account  of  nine  cases  illustrative  of  the  prompt  and  often 
permanent  relief  produced  by  the  hypodermic  application  of  narcotics  and  seda- 
tives in  various  distressing  cases  of  rheumatism,  gastrodynia,  neuralgia,  obsti- 
nate vomiting  towards  the  close  of  pregnancy,  and  spasms  from  a  dose  of  strych- 
nia taken  into  the  stomach.  Dr.  B.  H.  Catlin,  of  West  Meriden,  by  whom 
these  cases  are  reported,  states  that,  in  all  cases  save  one,  the  relief  was  prompt, 
decided,  and  permanent.  In  the  exceptional  case — that  of  a  feeble,  broken-down 
man,  65  years  of  age,  labouring  under  organic  disease  of  the  heart  of  several 
years'  standing — to  control  an  obstinate  vomiting  and  diarrhoea,  less  than  half  a 
grain  of  morphia  was  injected.  The  vomiting  ceased,  but  the  patient  began  to 
sink,  and  died  about  daylight  next  morning.  Dr.  C.  ascribes  the  fatal  event  to 
the  chronic  maladies  under  which  the  patient  had  long  laboured.  Not  half  the 
dose  of  morphia  employed  by  him  in  other  cases  with  good  effect  was  injected 
in  this,  while  the  little  effect  produced  by  the  large  and  repeated  doses  of  opium 
the  patient  had  previously  taken  by  the  stomach  showed  that  he  was  not  particu- 
larly sensible  to  the  impression  of  opiates. 

The  "Plastic  Constituents  of  the  Blood,  their  Physiological  and  Pathological 
Belations,"  is  the  title  of  the  next  communication.  It  is  by  Dr.  L.  J.  Sandford, 
of  New  Haven.  A  general  character  of  accuracy  pervades  the  facts  and  doc- 
trine set  forth  in  the  communication  of  Dr.  S.  It  comprises  but  very  few  new 
expositions  of  the  several  points  involved  in  the  general  subject  discussed — little 
that  calls  for  especial  comment. 

The  same  remarks  hold  true,  likewise,  in  respect  to  the  communication  which 
follows  the  above,  "On  the  Sympathetic  Nerve,"  by  Dr.  N.  G-.  Hall,  of  Vernon. 
Neither  of  these  two  papers — though  both  are  sufficiently  correct  and  interest- 
ing— is,  in  our  estimation,  of  a  character  that  should  command  for  it  a  place  in 
the  printed  transactions  of  a  State  Medical  Society.  Such  transactions  should 
be  the  medium  through  which  are  made  known,  for  the  enlargement  of  the 
general  fund  of  professional  knowledge,  the  personal  observations  of  practitioners 
scattered  over  the  face  of  the  country,  or  facts  of  general  application,  drawn 
from  the  aggregation  and  collation  of  the  observations  recorded  by  others,  cal- 
culated to  elucidate  the  etiology,  nature,  progress,  prevention,  and  treatment  of 
the  diseases  most  frequently  encountered  by  our  physicians.  Of  course,  we 
should  not  object  to  communications  giving  the  result  of  new  investigations 
regarding  the  physiology  of  any  part  of  the  human  organism,  or  of  a  new  expo- 
sition of  the  received  views  relative  to  the  laws  of  life. 

A  very  good  outline  sketch  of  the  symptomatology  and  general  features  of 
diphtheria,  as  it  recently  prevailed  epidemically  in  different  parts  of  Connecticut, 
is  presented  by  Dr.  G.  R.  Hawley,  of  Hartford.  It  presents  no  points  calling 
for  especial  notice. 

A  report  is  furnished  by  Dr.  D.  Crary,  of  Hartford,  of  two  anomalous  cases 
of  disease,  the  peculiar  feature  of  which  is  their  close  resemblance  to  each  other 
throughout;  so  much  so  that  the  narrative  of  one  would  be  that  very  nearly  of 
the  other. 

Both  patients  were  males,  of  steady  habits  and  uniformly  good  health;  both 
were  young  and  unmarried.  Davis,  who  was  driver  of  a  meat  cart,  was  of  a 
sanguine  temperament,  and  weighed  1G2  pounds.  Kazar  was  of  a  bilious  tem- 
perament; he  weighed  125  pounds,  and  worked  at  Colt's  pistol  factory.  Both 
boarded  at  the  same  house,  but  were  not  room-mates. 

On  Monday,  Davis  took  breakfast  and  dinner  as  usual,  and  worked  all  day. 
At  night  he  complained  of  headache  and  great  chilliness.  He  took  some  (so- 
called)  composition  powder,  and  went  to  bed.  Vomited  during  the  night  a  con- 
siderable amount  of  what  his  landlady  described  as  "yellow-looking  matter"  and 
of  orange-peel,  and  had,  also,  a  natural  stool.  In  the  morning,  he  looked  pur- 
plish about  the  face,  especially  under  the  eyes  ;  one  of  his  legs  presented  the 
same  discoloration.  Red  spots  were  observed  about  the  face,  neck,  and  breast. 
Dr.  Jackson  saw  him  between  8  and  9  o'clock  A.  M.  He  was  then  very  restless, 
tossing  from  side  to  side,  and  exclaiming,  "I'm  dying!  I'm  dying!  Can't  you 
help  me?"    He  at  first  seemed  to  recognize  the  doctor,  but  soon  relapsed  into 


1863.] 


Transactions  of  State  Medical  Societies. 


unconscious  delirium.  His  tongue  had  the  same  appearance  it  assumes  in  the 
semi-comatose  state  of  typhus ;  extremities  cool,  not  cold ;  pulse  at  wrist  imper- 
ceptible; eyes  much  injected  and  prominent;  skin  of  face,  thorax,  arms,  hands, 
legs,  and  feet  was  purple,  more  intense  in  some  places  than  in  others.  Circular 
spots,  from  one  to  three  lines  in  diameter,  and  somewhat  like  what  is  known  as 
blood-blisters,  appeared  upon  the  face  and  neck.  The  tongue  had  a  dark  coat- 
ing, and  the  lips  and  teeth  were  loaded  with  similar  coloured  sordes.  Death 
took  place  at  about  9  A.  M.  of  the  same  day. 

When  he  heard  at  noon  that  Davis  was  dead,  Kazar  went  into  the  room  where 
the  corpse  lay.  On  his  return  he  seemed  much  frightened,  was  pale,  and  scarce 
able  to  stand.  At  table  he  ate  very  little.  At  3  o'clock  he  returned  from  his 
work,  complaining  of  cold.  During  the  afternoon  he  had  frequent  chills.  On 
going  to  bed  in  the  evening  he  took  some  "  composition  powder."  During  the 
night  he  vomited  great  quantities  of  very  dark  bilious-looking  matter,  and  had 
also  a  natural  passage  from  the  bowels.  In  the  morning  Dr.  Gary  found  him 
pulseless,  with  nearly  cold  feet  and  hands,  and  a  furred  blanched  tongue,  similar 
to  what  is  met  with  in  the  last  stages  of  cholera.  Petechia?  were  scattered 
over  almost  the  entire  surface.  His  face,  hands,  and  feet,  his  arms  to  the 
elbows,  and  his  legs  to  the  knees,  were  covered  with  petechial  spots  of  all  sizes 
from  that  of  a  half  dime  to  that  of  a  dollar  or  over.  The  face  presented  a  com- 
mingling of  black  and  blue  welts  one  or  two  inches  long,  as  though  caused  by 
the  blow  of  a  whip.  His  mind  was  perfectly  clear  and  calm.  He  complained 
of  pain  of  the  head  over  the  eyes,  with  coldness  of  hands  and  feet.  He  stated 
that  on  his  way  home  the  preceding  afternoon  he  had  taken  a  glass  of  cider 
brandy,  after  which,  for  a  short  time,  he  felt  better. 

A  consultation  was  had  with  Drs.  Hastings  and  Jackson,  and  the  patient  put 
on  the  use  of  quinine,  brandy,  and  pepper,  with  hot  applications  to  the  extremi- 
ties.   No  reaction  took  place,  and  the  patient  died  at  about  11  o'clock  A.  M. 

The  small  spots  scattered  irregularly  over  Davis's  face  and  neck,  of  the  size 
each  of  a  No.  B  shot,  appeared  after  death  of  a  bright  scarlet  colour  ;  the  small 
spots  on  Kazar  were  smaller,  not  so  bright,  but  more  like  the  petechias  of  typhus 
fever.  Davis,  but  not  Kazar,  up  to  the  period  of  his  death,  had  extreme  thirst. 
Davis  lived  from  the  beginning  of  the  attack  about  fifteen  hours,  Kazar  twenty- 
one  hours. 

The  history  of  a  case  of  cerebro-spinal  disease  is  reported  by  Dr.  E.  Deming, 
of  Sharon.  So  far  as  the  facts  connected  with  this  case  are  furnished  in  the 
history  before  us,  they  are  both  curious  and  interesting — it  might  have  been 
rendered  instructive  also,  had  an  examination  of  the  patient's  body  been  made 
after  death.  As  it  is,  the  case  furnishes  no  light  to  lead  us  to  definite  judg- 
ment as  to  the  true  pathology  of  any  attack,  marked  by  similar  phenomena,  we 
might  happen  to  meet  with. 

The  notes  of  a  case  of  ligation  of  the  external  iliac  artery  are  given  by  Dr. 
J.  W.  Lawton,  of  Naugatuck.  The  patient  received  a  stab  one  evening  from 
a  long  penknife  blade  in  the  right  thigh,  three  or  four  inches  below  Poupart's 
ligament,  the  wound  being  in  a  direction  upwards  and  outwards  in  the  line  of  the 
adductor  longus  muscle.  From  twenty  to  thirty  ounces  of  blood  were  lost.  A 
temporary  dressing  was  applied,  until  the  patient  was  removed  to  his  home ;  when, 
as  the  hemorrhage  was  nearly  arrested,  no  examination  of  the  wound  was  made, 
but  merely  a  compress  and  bandage  were  applied.  Reaction  was  established, 
and  the  next  day  the  patient,  though  weak,  was  otherwise  comfortable.  The 
symptoms  proceeded  favourably  for  a  week.  On  the  eleventh  day  the  patient 
became  restless  and  uneasy,  and  a  strong  arterial  impulse  was  noticed.  As  Dr. 
L.  bent  down  to  examine  the  wound,  blood  gushed  from  it,  in  a  full  stream,  to 
the  amount  of  twenty  ounces.  By  the  application  of  a  compress,  and  a  silk 
.handkerchief  as  a  tourniquet,  the  hemorrhage  was  completely  controlled.  Drs. 
Piatt  and  Hooker  were  called  in  consultation.  The  wound  was  now  thoroughly 
examined,  the  clots  broken  up,  and  warm  water  injected,  without  any  return  of 
hemorrhage.  The  finger  passed  into  the  wound  detected  the  pulsation  of  the 
femoral  artery.  Any  operation  was  deemed  inexpedient,  from  the  danger  at- 
tending it — the  risk  of  secondary  hemorrhage,  and  the  uncertainty  as  to  what 
artery  was  wounded.    Pressure  alone,  by  means  of  a  tourniquet  and  compress , 


148 


Bibliographical  Notices. 


[Jan. 


was  relied  upon.  This  was  watched  by  faithful  assistants,  with  instructions  to 
inc  rease  instantly  the  pressure  should  bleeding  occur.  On  the  second  night 
subsequently  ten  ounces  of  blood  were  lost. 

October  4th,  eighteen  days  after  the  accident,  bleeding  occurred  at  intervals 
during  the  day.  At  4  P.  M.,  notwithstanding  constant  pressure  was  made  over 
the  groin,  blood  would  jet  out  at  times,  in  fine  streams,  to  the  height  of  several 
inches.  The  parts  had  become  tender  and  intolerant  of  pressure.  Ligation  of 
the  external  iliac  was  now  performed  by  Dr.  Hooker.  The  wound  was  dressed 
with  silver  wire  sutures,  adhesive  straps,  and  compresses.  Three  hours  after  the 
operation  the  patient  complained  of  some  pain,  and  vomited  constantly  from  the 
effects  of  ether.  A  sixth  of  a  grain  of  morphia  directed  to  be  given  occasion- 
ally. Two  days  subsequently  vomiting  unchecked,  limb  warmer  than  natural, 
and  so  continued  for  weeks  ;  it  was  quite  tender,  patient  very  restless.  Bismuth 
and  calomel  ordered.  At  night  pain  increased,  knee  swollen.  The  patient  be- 
came more  stupid,  restless  ;  suffered  severe  pain  ;  tongue  brown,  dry,  and  coated. 
Morphia  discontinued,  while  milk  punch  and  generous  diet  were  ordered. 

Oct.  8th.  Patient  comatose ;  knee  exquisitely  tender,  with  indistinct  fluctua- 
tion ;  pulse  110  to  115.  In  addition,  ten  grains  quinia  per  day  were  ordered, 
with  fomentations  to  knee.  The  next  day  the  patient  was  apparently  moribund. 
The  day  after,  the  patient  was  found  to  be  rational,  his  limbs  cool,  pulse  80  and 
weak.  Same  treatment  continued.  By  night  the  pulse  was  stronger,  and  all 
the  other  symptoms  more  favourable.  From  this  time  the  patient  gradually 
improved.  The  ligatures  all  came  away  except  one,  which  remained  in  nearly 
four  weeks. 

During  the  period  of  convalescence  a  swelling  occurred  at  the  angle  of  the 
lower  jaw,  on  the  right  side,  which  increased  rapidly,  involving  the  side  of  the 
face  and  neck,  extending  down  upon  the  chest.  It  terminated  in  a  large  abscess, 
an  incision  into  which  gave  discharge  to  nearly  half  a  pint  of  pus  with  sloughs 
of  parotid  gland.  The  discharge  continued  for  several  weeks,  and  the  incision 
healed.  The  knee  now  grew  worse,  inflamed  and  painful,  with  an  indistinct 
feeling  of  fluctuation. 

Dec.  10th.  The  patient  was  removed  to  the  hospital  at  New  Haven,  under 
the  care  of  Dr.  Charles  Hooker.  From  this  time  his  general  condition  con- 
stantly improved  ;  the  knee,  however,  remained  flexed  and  anchylosed. 

D.  F.  C. 


Art.  XXI. — Reports  of  American  Institutions  for  the  Insane. 

1.  Of  the  Pennsylvania  Hospital  for  the  Insane,  for  the  year  1861. 

2.  Of  the  Friends'  Asylum,  for  the  fiscal  year  1861-62. 

3.  Of  the  Western  Pennsylvania  Hospital,  for  the  year  1861. 

4.  Of  the  Bloomingdale  Asylum,  for  the  year  1861. 

5.  Of  the  McLean  Asylum,  for  the  year,  1861. 

6.  Of  the  Massachusetts  State  Hospital,  at  Northampton,  for  the  fiscal  year 
1860-61. 

7.  Of  the  Longview  Asylum,  for  the  year  1861. 

8.  Of  the  New  Hampshire  Asylum,  for  the  fiscal  year  1861-62. 

1.  Should  the  progress  of  the  next  century,  in  the  province  of  psychiatry,  be 
equal  to  that  of  the  century  at  the  termination  of  which  we  write,  the  problem 
of  The  Perfect  Hospital  for  the  Insane  can  hardly  fail  of  being  solved.  In  this 
remark  we  allude  not  alone  to  the  minor  details  of  organization,  classification, 
discipline,  and  the  diversified  means  for  the  administration  of  a  perfect  moral 
treatment,  but  to  the  great  primary  question  of  the  character  of  the  hospital 
as  it  regards  the  sexes,  and  the  duration  of  the  disease  of  its  patients.  The 
Germans  have  tried  almost  every  form  of  hospital  in  these  respects,  without, 
hitherto,  arriving  at  unanimity  of  opinion  upon  the  subject;  but,  so  far  as  our 
knowledge  extends,  they  have  not  tried  that  which  has  recently  been  adopted 
at  the  Pennsylvania  Hospital  for  the  Insane — the  intermingling  of  both  recent 


1863.] 


American  Insane  Hospital  Reports. 


149 


151 

123 

274 

96 

86 

182 

247 

209 

456 

119 

82 

201 

128 

127 

255 

46 

46 

92 

21 

8 

29 

and  chronic  cases,  but  the  separation  of  the  sexes  by  buildings  somewhat  remote 
each  from  the  other,  yet  both  under  the  same  general  administration  and  the 
same  physician  in  chief.  It  is  an  experiment  challenging  the  attention  and  the 
interest  not  only  of  American  but  also  of  European  colonists.  The  testimony 
borne  by  Dr.  Kirkbride  in  relation  to  the  subject,  after  his  second  year  of  trial, 
is  as  follows : — 

"Another  year's  experience  has  confirmed  our  previous  impressions  of  the 
great  value  of  the  new  arrangements,  and  has  demonstrated  more  fully,  if  addi- 
tional proof  were  still  wanting,  that  the  treatment  of  the  two  sexes  in  different 
buildings,  as  here  conducted,  without  having,  as  far  as  we  can  discover,  a  single 
objection,  has  unquestionably  many  and  important  advantages." 

This  certainly  looks  encouraging  ;  but  it  is  no  more  so  than  we  expected  after 
having  visited  the  Institution,  examined  both  departments  with  all  their  admir- 
able arrangements  and  appliances,  and  duly  considered  the  whole  establishment 
in  its  relation  and  adaptation  to  the  wants  of  the  insane. 

Men.    Women.  Total. 

Patients  in  hospital  Jan'y  1st,  1861  . 
Admitted  in  course  of  the  year  . 

Whole  number  

Discharged,  including  deaths  . 
Remaining,  Dec.  31,  1861  .... 
Of  the  discharged,  there  were  cured  . 
Died  

Causes  of  death. — "Acute  maniacal  disease,"  10;  chronic  softening  of  the 
brain,  5 ;  pulmonary  consumption,  4 ;  exhaustion  of  chronic  mania,  3  ;  apoplexy, 
3;  suicide,  1 ;  disease  of  heart,  1;  dropsy,  1 ;  "effects  of  a  long  journey,"  1. 

"The  sixteenth  annual  course  of  lectures  and  evening  entertainments  which 
terminated  at  the  usual  period  of  the  last  summer,  was,  as  those  heretofore 
given,  of  nine  months'  duration — three  times  a  week  at  least,  at  each  depart- 
ment— .and  occupying  about  two  hundred  and  fifty  evenings.  These  entertain- 
ments being  on  alternate  evenings  at  the  two  buildings,  anything  of  special 
interest  occurring  at  one,  can  be  enjoyed  by  patients  from  the  other ;  and  this 
has  been  frequently  done.  A  company  of  forty  ladies  has  on  several  occasions 
gone  to  the  new  building  during  the  past  year." 

"Every  year  adds  to  the  conviction  of  the  great  importance  of  these  enter- 
tainments in  the  management 'of  a  hospital  for  the  insane.  It  is  quite  possible, 
with  proper  zeal  and  determination,  to  make  the  evening  hours  in  such  institu- 
tions the  most  pleasant  in  the  whole  day.  Without  some  decided  effort,  however, 
this  period  is  apt  to  become  specially  tiresome,  and  the  wards,  then,  to  present 
their  most  listless  and  discouraging  appearance.  From  sunset  to  bedtime  there 
should  be  a  persistent  effort  on  the  part  of  all,  to  have  something  on  hand  that 
will,  at  least  to  some  extent,  excite  the  interest  and  attract  the  attention  of  even 
those  of  least  mental  activity.  The  first  step  is  to  have  the  corridors  and  par- 
lours cheerfully  lighted  and  comfortably  furnished,  to  have  in  progress  agreeable 
work,  pleasing  games,  interesting  to  lookers  on  as  well  as  players,  pictures  of 
various  kinds,  pleasant  reading  or  music,  and  varying  novelties  that  those  best 
qualified  for  positions  here  will  be  constantly  suggesting.  In  this  work  the 
officers  of  course  must  take  the  lead.  There  must  be  nothing  likely  to  benefit 
the  patients  ever  so  little,  too  small  or  too  low  for  their  attention  and  interest. 
In  this  connection  the  services  of  the  supervisors  and  of  those  employed  spe- 
cially as  companions  to  the  patients,  on  account  of  the  greater  amount  of  time 
they  may  devote  to  it.  become  particularly  valuable.  No  less  important  is  the 
interest  of  the  attendants  in  their  various  wards,  nor  the  assistance  of  conval- 
escent patients,  who  often  confer  great  benefits  on  those  around  them. 

"As  a  general  rule,  the  evenings  devoted  to  lectures  are  pretty  well  occupied 
in  preparing  for  them,  by  the  hour  in  the  room,  and  a  pleasant  talk  on  what  has 
been  seen  or  heard,  afterwards.  The  other  evenings  of  the  week  should  never 
be  neglected,  as  there  is  always  some  danger  of  their  being. 

"  In  nearly  all  cases,  life,  to  be  really  happy,  must  be  one  of  action.  Especially 


150 


Bibliographical  Notices. 


[Jan. 


is  it  so  in  a  hospital  like  this.  From  the  hour  of  rising  in  the  morning  till  that 
of  retiring  at  night,  except  in  cases  of  ordinary  illness  or  high  excitement,  almost 
constant  movement,  change  of  occupation,  variety  of  scene  and  surroundings, 
cheerful  physical  exercise  and  prudent  mental  employment  are  needed  for  every 
day,  to  develop  the  most  successful  results  and  aid  in  promoting  cheerfulness 
and  tranquillity  in  the  wards.  In  carrying  out  all  these  objects,  it  must  not 
be  forgotten  that  they  lose  half  their  value  if  done  simply  as  a  required  duty, 
without  that  personal  interest  and  hearty  good-will  which  rarely  fails  to  convince 
patients,  that  what  is  urged  upon  them,  is  really  intended  to  promote  their  com- 
fort and  restoration." 

In  all  our  reading  of  the  reports  of  hospitals  for  the  insane,  we  have  met 
nothing  more  gratifying,  nothing  more  truly  indicative  of  a  consciousness  of  one 
of  the  greatest  stumbling-blocks  of  the  hospital  as  it  was,  or  of  the  necessity 
and  the  true  method  of  removing  that  stumbling-block  before  we  can  obtain  the 
hospital  that  is  to  be,  than  the  foregoing  extract.  Dr.  Kirkbride's  words  "spe- 
cially tiresome,"  entirely  fail  adequately  to  express  the  character  of  the  evenings 
in  the  hospitals  of  the  olden  time.  The  corridors  in  darkness,  or  each  lighted 
by  one  miniature  flame  which  only  served  to  throw  a  sepulchral  gloom  along  its 
wearisome  length ;  the  silence,  unbroken  but  by  the  occasional  raving  of  a 
maniac,  or  the  gibberish  of  an  imbecile ;  the  stealthy,  solemn,  and  solitary  pac- 
ing to  and  fro,  in  the  gloomiest  portion  of  the  hall,  of  some  patient  absorbed  in 
the  contemplation  of  his  delusions;  the  lounging  in  chairs,  the  squatting  in 
corners  and  along  the  side-walls,  and  the  lying  at  full  length,  on  back  or  on  belly, 
upon  the  floor — these  presented  a  picture — alas  !  not  a  picture,  but  a  sad  reality, 
a  concrete  embodiment  of  monotonous  sluggishness,  of  ineffable  stupidity,  of  a 
mental  and  physical  apathy  injurious  to  the  participator,  and  depressing  and 
discouraging  to  the  beholder.  As  the  frog,  in  the  mathematical  proposition,  lost 
at  night  two  of  the  three  feet  which,  in  his  worthy  endeavours  to  escape  from  the 
well,  he  had  gained  in  the  course  of  the  preceding  twelve  hours,  so,  we  have 
often  thought,  the  patients  subjected  to,  or  permitted  in,  this  course  of  melan- 
choly listlessness,  "  fell  back"  in  the  evening  through  at  least  two-thirds  of  the 
distance  toward  health  achieved  during  the  day. 

It  needs  no  spirit  of  prophecy  other  than  that  derived  from  a  mediocre  know- 
ledge of  human  nature  to  foretell  the  effects,  or  at  least,  the  tendency  of  our 
national  difficulties  upon  our  hospitals  for  the  insane.  Those  effects  should,  if 
possible,  be  prevented,  that  tendency  opposed.  Hence,  we  reproduce  the  fol- 
lowing remarks,  believing  that  they  will  be  indorsed  by  every  physician  of  long 
experience  in  the  management  of  one  of  those  hospitals  : — 

uNo  matter  whether  an  institution  is  specially  for  the  affluent,  for  the  recep- 
tion of  all  classes,  or  the  humblest  pauper  hospital  in  the  land,  true  economy 
consists  in  an  avoidance  of  all  waste,  in  having  nothing  done  that  is  not  useful 
in  some  way,  in  keeping  everything  in  the  highest  state  of  efficiency,  and  doing- 
all  that  is  likely  to  restore  to  society  its  afflicted  citizens  in  the  shortest  possible 
time.  The  best  arrangements  wil^always  be  found  cheapest  in  the  end,  and  the 
highest  class  of  qualifications  in  every  department,  with  liberal  compensation, 
will  prove  more  economical  than  inefficiency  at  the  lowest  grade  of  remuneration. 

"  In  periods  of  unusual  financial  depression,  when  nearly  every  one  is  apt  to 
feel  the  necessity  for  a  reduction  of  personal  expenses,  there  is  always  danger 
of  the  management  of  these  institutions  for  the  cure  as  well  as  the  care  of  the 
insane,  making  the  grave  mistake  of  doing  something  as  a  means  of  lessening 
their  expenses,  that  must  unavoidably  lower  their  character  and  impair  their 
usefulness.  Retrenchments  may  thus  be  carried  to  that  point  that  they  become 
absolute  extravagance.  This  is  clearly  so  if  they  diminish  the  usefulness  of  an 
institution,  lessen  the  confidence  of  the  public  in  its  efficiency,  and  thus  reduce 
its  income  to  a  far  greater  extent  than  they  lower  its  expenditures.  It  can 
never  be  economy  to  neglect  any  available  means  of  restoring  the  sick,  of  im- 
proving the  condition  of  all  the  patients,  and  doing  thoroughly  what  an  institu- 
tion has  been  specially  established  for.  One  establishment  may  expend  scarcely 
more  than  half  what  another  does,  and  yet  if  these  expenditures  are  injudicious, 
it  may  be  both  wasteful  and  extravagant,  while  the  other  is  truly  economical." 


1863.] 


American  Insane  Hospital  Reports. 


151 


2.  Of  the  comparatively  small,  but  the  truly  comfortable  and  domestic,  or 
home-like  Friends'  Asylum,  Dr.  Worthington  says  : — 

"  Originating  at  a  time  when  no  institution  existed  in  this  country,  that  could 
serve  as  a  model  for  its  plan  of  construction,  the  founders  of  the  asylum  showed, 
by  the  quantity  of  land  purchased,  and  by  the  amount  of  space  allotted  to  each 
patient,  in  the  construction  and  general  plan  of  the  building,  a  degree  of  liberality 
which  has  probably  not  since  been  surpassed.  How  far  the  asylum  may  have 
been  successful  in  other  respects  in  keeping  pace  with  the  progress  of  improve- 
ment, or  how  far  the  means  employed  in  it,  as  compared  with  other  institutions, 
may  have  contributed  to  the  relief  and  restoration  of  the  insane,  is  not  for  us  to 
judge.  It  will  be  sufficient  to  say  that  during  the  past,  as  in  previous  years,  we 
have  felt  the  responsibility  resting  on  us  of  diligently  employing,  for  the  benefit 
of  our  patients,  every  means  within  our  reach,  which  the  general  experience  has 
proved  to  be  of  real  utility. 

''The  objects  of  its  founders,  besides  furnishing  medical  aid,  and  suitable 
moral  and  religious  restraint,  mingled  with  judicious  kindness  and  sympathy, 
for  the  restoration  of  the  insane  to  the  inestimable  gift  of  reason,  were  also  to 
provide  an  asylum  for  the  relief  of  those  whose  disease  was  such  as  to  leave  no 
hope  of  recovery ;  where  they  might  enjoy  the  comforts  of  home  so  far  as  they 
were  capable  of  appreciating  them,  accompanied  with  every  liberty  consistent 
with  their  welfare  and  safety.  These  objects,  it  is  believed,  have  been  kept 
steadily  in  view,  and  it  has  been  found,  by  constantly  increasing  experience, 
that  the  amount  of  personal  restraint  on  the  movements  of  the  insane,  deemed 
necessary  for  their  own,  and  the  safety  of  others,  has  regularly  diminished  down 
to  the  present  time.  We  have  not  in  any  case,  for  several  years  past,  considered 
it  needful  to  apply  mechanical  restraint  for  the  prevention  of  acts  of  violence 
and  destruction,  and  we  have  only  resorted  to  it  in  any  form  in  cases  where 
severe  bodily  disease  or  debility  has  rendered  a  recumbent  position  indispensa- 
ble to  the  safety  of  the  patient's  life." 

The  Italics  are  by  the  reviewer,  and  not  by  the  author. 


Patients  on  the  1st  of  March,  1861 
Admitted  in  the  course  of  the  year 
Whole  number  .... 
Discharged,  including  deaths 
Eemaining,  March  1st,  1862 
Of  those  discharged,  there  were  cured 
Died        .      .  . 


Men.  Women.  Total. 


61 

15 

32 

44 

76 

6 

8 

14 

26 

36 

62 

3 

3 

6 

1 

3 

4 

Causes  of  death. — Cerebral  congestion,  1 ;  pneumonia,  1 ;  general  paralysis,  1 ; 
chronic  bronchitis,  1. 

The  lectures  and  other  evening  entertainments  were  resumed  and  continued 
through  the  winter.  The  lectures  were  "listened  to,  and  the  experiments  wit- 
nessed with  much  interest,  by  a  large  proportion  of  the  patients."  From  the 
further  exposition  of  the  plan  of  moral  treatment  we  make  a  few  extracts. 

"  The  value  of  out-door  occupation  consists  as  much  in  the  change  and 
variety  it  gives  from  the  monotony  of  in-door  asylum  life,  and  the  mental  recrea- 
tion thus  afforded,  as  in  the  mere  physical  effects  of  muscular  exercise.  Without 
regard  to  the  interest  that  may  be  excited  in  the  mind  of  the  patient  by  the  work 
he  performs,  there  is  danger  that  the  latter,  by  becoming  toilsome,  may  even 
prove  injurious.  Care  is  taken  to  avoid  such  a  consequence  by  endeavouring 
to  interest  the  patient  in  his  employment,  and  by  limiting  the  time  spent  in 
labour  to  two  or  three  hours  in  the  early  part  of  each  day.  *  *  *  *  For 
those  who  have  been  unaccustomed  to  agricultural  labour,  other  means  of 
furnishing  physical  exercise,  combined  with  healthy  mental  excitement,  are 
resorted  to.  Such  patients  spend  a  portion  of  each  day  in  the  open  air,  either 
in  walking  on  the  premises  or  in  the  vicinity  of  the  asylum,  or  are  engaged  in 
the  games  of  quoits,  cricket,  or  foot-ball.  The  latter  have  only  been  in  use 
during  the  last  two  years,  and  have  proved  a  highly  valuable  addition  to  the 
means  formerly  employed  for  affording  exercise  to  this  class  of  our  patients." 


152 


Bibliographical  Notices. 


[Jan. 


"  The  patients  are  encouraged  to  follow  their  own  taste  and  inclinations  in 
their  in-door  employments.  Some  of  them  became  quite  expert  at  a  particular 
game,  such  as  chess  or  backgammon ;  one  patient  draws  and  paints,  and  has 
produced  a  number  of  pictures,  both  in  oil  and  water  colours,  which  have  been 
framed  and  hung  on  the  walls.  Another  employed  himself  very  successfully 
during  the  portion  of  the  summer,  in  preparing  the  skeletons  of  leaves  and 
other  portions  of  plants;  and  another,  who  is  so  demented  as  to  be  almost 
incapable  of  any  other  employment,  has  become  very  proficient  in  the  game  of 
battledoor." 


3.  Our  readers  have  already  been  informed  of  the  efforts  made  by  the  mana- 
gers of  the  Western  Pennsylvania  Hospital  to  erect,  for  their  insane  patients, 
a  new  building  which  should  rank  among  the  best  institutions  of  its  kind,  as 
well  as  of  the  progress  which,  from  year  to  year,  they  have  made  in  their  enter- 
prise. The  report  now  before  us  is  embellished  with  a  beautiful  perspective 
view  of  the  building  as  it  is  intended  to  be  when  complete.  It  is  called  "  The 
Dixmont  Hospital."  Of  its  condition  at  the  date  of  this  report,  as  well  as  for 
its  general  plan,  we  quote  the  language  of  its  architect,  whose  report  is  a  model 
of  compactness  and  perspicuity  which  might  well  be  studied  by  scientific  and 
literary  men. 

"  The  work  on  the  new  buildings  of  the  Hospital  for  the  Insane  at  Dixmont, 
is  now  nearly  completed,  the  plastering  being  finished,  and  the  carpenters  being 
now  engaged  in  putting  up  the  finishing  of  the  wood  work  inside  of  the  build- 
ing. Excepting  the  fixtures  for  heating,  ventilation  and  water  supply,  which 
are  all  yet  to  be  provided  for,  the  buildings  will  be  completed  and  ready  for 
occupancy  by  the  1st  of  May  next. 

"The  hospital  proper  consists  of  a  central  building,  sixty-one  feet  front  by 
one  hundred  and  thirty  deep,  and  four  stories  in  height,  arranged  for  the  use  of 
the  officers,  and  to  form  store  rooms  and  chapel.  On  each  side  of  this  central 
building  extends  a  wing  building,  one  hundred  and  four  feet  front  by  thirty- 
eight  feet  deep,  and  three  stories  in  height,  arranged  with  dormitories  for  use  of 
the  patients ;  each  wing  finishing  with  a  building  at  the  end  of  it,  forty-five 
feet  front  by  fifty-five  feet  deep,  and  four  stories  in  height,  arranged  for  day 
rooms  of  the  patients.  These  buildings  are  erected  with  walls  of  brick,  covered 
with  roofs  of  iron,  and  have  stone  stairways,  the  whole  being  substantially  con- 
structed and  finished  in  a  neat,  plain  manner,  the  plan  being  arranged  in  reference 
to  future  extension  by  addition  of  other  wings,  to  accommodate  more  patients. 

"Detached  from  the  hospital  is,  first,  a  building  for  the  laundry,  bakery  and 
boiler  room,  forty-five  feet  by  fifty-five,  and  two  stories  high,  built  of  stone  and 
covered  with  iron.  Next,  a  building  at  the  river  for  a  pump  house,  twenty-six 
feet  square  and  one  story  high,  built  of  stone  and  covered  with  iron  roofing. 
Lastly,  a  building  for  station  house  at  the  railroad,  seventeen  feet  by  thirty-two, 
built  of  brick  and  roofed  with  iron." 

It  is  proper  to  state  that  the  plan  of  the  hospital  embraces  two  additional 
wings,  very  similar  to  those  already  erected  and  to  be  appended  to  their  extremi- 
ties. 

Men.  Women.  Total. 

Patients  in  the  Western  Pa.  Hosp.,  Jan.  1st,  1861 
Admitted  in  the  course  of  the  year 

Whole  number  

Discharged,  including  deaths 
Eemaining,  Dec.  31st,  1861 
Of  the  discharged,  there  were  cured  . 
Died  .'. 


59 

52 

111 

63 

32 

95 

122 

84 

206 

55 

41 

96 

67 

43 

110 

31 

19 

50 

6 

4 

10 

Died  of  consumption,  2  ;  exhaustion  of  acute  mania,  2  ;  enteritis,  2 ;  chronic 
dysentery,  1  ;  congeslion  of  the  brain,  1;  typhoid  fever,  1;  old  age,  1. 
In  pleading  for  additional  facilities  for  moral  treatment,  Dr.  Eeed  says  : — 
"  As  a  relief  from  trouble  and  anxiety  of  mind,  men  resort  to  occupation  and 
pleasant  amusements,  and  when  the  mind  has  become  deranged  the  necessity 
for  such  treatment  is  greater.    It  is  not  inaction  that  is  desired  to  accomplish 


1863.] 


American  Insane  Hospital  Reports. 


153 


a  cure,  but  a  change  of  action.  In  recent  insanity  the  mind  will  not  rest,  and 
unless  constant  and  urgent  inducements  to  healthy  action  are  presented,  and 
new  channels  opened  for  the  thoughts  and  affections,  the  patient  will  indulge 
in  his  perverted  feelings  and  distorted  ideas,  until  dementia  places  him  beyond 
hope.  It  is  this  condition  we  wish  to  prevent,  or  at  least  postpone.  We  desire 
not  to  abandon  the  patient  to  blind  chance,  or  allow  him  to  grow  worse  by 
neglecting  to  provide  every  proper  remedy." 

When  his  patient  shall  have  been  removed  to  Dixmont,  the  doctor  may  look 
with  a  larger  hope  and  a  firmer  faith  for  a  more  complete  equipment  for  the 
battle  against  the  disease  with  which  he  is  contending. 

From  what  follows,  it  appears  that  the  insane  have  not  lost  their  patriotism 
or  their  beneficence. 

"One  hundred  and  ten  shirts  were  made  for  the  soldiers  at  Washington,  by 
the  patients  and  employees,  the  materials  having  been  purchased  by  the  con- 
tributions of  officers  and  employees." 


4.  It  must  have  required  labour  to  make  the  report  of  the  Blooming  dale 
Asylum.  What  with  one-third  of  a  page  of  margin  at  its  beginning,  and  one 
quarter  of  a  page  at  the  end,  it  occupies  two  pages. 


Patients  Jan'y  1st,  1861  . 
Admitted  in  course  of  the  year 
Whole  number  .... 
Discharged,  including  deaths 
Of  the  discharged,  there  were  cured 
Died  


Men.  Women. 
71  84 


60 
131 
58 
22 
12 


51 
135 
57 
20 
7 


Total. 
155 
111 
266 
115 
42 
19 


"  Several  patients  discharged  improved,"  says  Dr.  Brown,  "  are  known  to 
have  recovered  after  returning  to  their  homes.  The  deaths  were  occasioned,  in 
six  cases,  by  acute  mania,  with  great  excitement ;  in  two  by  general  paralysis  ; 
in  two  by  chronic  disease  of  the  brain  with  partial  paralysis ;  in  two  by  apoplexy; 
in  one  by  suicide  ;  in  five  by  pulmonary  consumption  and  marasmus  ;  in  one  by 
disease  of  the  kidneys.    Four  patients  died  within  a  fortnight  after  admission. 

"  While  the  average  number  of  patients  for  the  year  as  compared  with  that  of 
the  previous  one,  is  scarcely  less,  there  is  an  actual  diminution  of  twenty  in 
comparing  our  present  household  with  that  of  some  portion  of  last  year.  This 
falling-off  is  occasioned  by  the  wide-spread  pecuniary  reverses,  compelling  the 
removal  of  many  patients  to  State  and  municipal  institutions." 


5.  The  McLean  Asylum  has  been  enlarged  by  the  erection  of  a  wing  intended 
for  the  cases  of  insanity  in  its  more  severe  and  violent  forms.  "  The  apartments 
are  spacious  and  cheerful,  and  thoroughly  ventilated ;  and  for  comfort,  elegance, 
and  adaptation  to  the  use  designed,  are  unequalled." 


Patients,  January  1st,  1861 
Admitted  in  course  of  the  year 
Whole  number  . 
Discharged,  including  deaths 
Eemaining,  Dec.  31st,  1861 
Of  the  discharged,  there  were  cured 
Died  


Men.  Women. 
91  96 


55 
146 
60 
96 
.31 
9 


56 
152 
50 
92 
23 
14 


Total. 
187 
111 

298 
110 

188 
54 
23 


Died  from  chronic  insanity,  8  ;  general  paralysis,  5 ;  typhomania,  3 ;  chronic 
disease  of  the  liver,  2  ;  phthisis,  2  ;  epilepsy,  2  ;  apoplexy,  1. 

Dr.  Tyler  has  devoted  nearly  the  whole  of  his  report  to  a  dissertation  upon 
the  psychological  condition  of  the  country,  as  affected  by  the  war. 

6.  The  leading  statistics  of  the  report  of  the  Massachusetts  State  Lunatic 
Hospital,  at  Northampton,  are  as  follows : — 


154 


Bibliographical  Notices. 


[Jan. 


Patients,  September  30,  1860  . 
Admitted  in  course  of  the  year  . 
Whole  number  . 
Discharged,  including  deaths 
Kemaining,  September  30,  1861, 
Died  


Men. 

Women. 

Total. 

137 

178 

315 

70 

52 

122 

207 

230 

437 

58 

47 

105 

149 

183 

332 

15 

15 

30 

Died  with  phthisis,  9  ;  marasmus,  8 ;  epilepsy,  3 ;  maniacal  exhaustion,  2  ; 
pneumonia,  2 ;  cancer,  softening  of  brain,  typhomania,  general  paralysis,  apo- 
plexy, chronic  diarrhoea,  1  each. 

In  allusion  to  the  number  of  patients  who  died  "  from  the  slow  wasting  away 
which  removed  so  many  in  the  last  stages  of  chronic  dementia,"  Dr.  Prince 
says : — 

"  Of  these  cases  we  have  a  very  large  proportion  received  from  the  other 
hospitals  at  the  opening  of  this  institution.  This  fact  will  for  several  years 
make  our  mortality  larger  than  the  average  in  hospitals,  and  also  give  an  extra- 
ordinary proportion  of  deaths  from  chronic  diseases." 

It  is  to  be  regretted  that  the  number  of  cures  is  not  stated.  We  perceive  no 
motive  for  withholding  it  other  than  that,  from  the  proportion  of  chronic  cases 
in  the  establishment,  it  is  undoubtedly  small.  But  all  proper  allowance  would 
be  made  for  that,  and  it  is  a  pity  that  the  statistics  of  insanity  should  not  be 
kept  as  full  and  as  accurate  as  possible. 

"  Our  means  of  amusement  have  been  enlarged  by  the  addition  of  a  bowling 
alley,  containing  two  boards.  An  appropriation  of  eight  hundred  dollars  was 
made  by  the  last  legislature  for  the  purpose,  and  a  substantial  brick  building 
has  been  placed  in  a  convenient  spot,  containing  everything  needed.  It  will 
soon  be  finished  and  occupied,  and  add  greatly  to  the  health  and  recreation  of 
those  for  whom  it  was  designed. 

"  A  billiard  table  was  considered  such  an  indispensable  article  of  furniture, 
that  one  has  been  placed  in  a  convenient  position  (thus  far  without  cost  to  the 
institution  or  the  State),  in  the  hope  that  its  importance  as  a  means  of  exer- 
cise, health,  and  amusement,  would  be  acknowledged,  and  the  means  of  securing 
so  desirable  an  article  be  furnished. 

"  Under  the  general  head  of  amusements  maybe  included  the  usual  games 
made  use  of  as  relaxative,  besides  walking,  fishing,  hunting,  pic-nics,  excursions 
to  points  of  interest,  reading,  concerts,  dances,  &c,  all  of  which  serve  to  vary 
the  monotony  of  hospital  life,  and  excite  new  and  interesting  currents  of  thought. 

"  The  library  has  been  increased  somewhat,  both  by  purchase  and  by  dona- 
tions from  friends  of  the  institution  or  of  the  patients.  New  pictures  have  been 
added  to  those  which  already  adorned  the  walls.  A  room  has  been  fitted  as  a 
reading-room,  and  supplied  with  the  daily  papers,  thus  supplying  a  want  long 
felt  and  regretted." 

Several  pages  of  the  report  are  occupied  by  an  appeal  for  special  provision 
for  the  treatment  of  habitual  inebriates,  but  nearly  the  whole  of  it  is  quoted  from 
the  writings  of  Dr.  Kirkbride. 

The  extract  given  below  shows  the  quality  of  the  water  to  the  use  of  which 
the  inmates  of  this  hospital  are  subjected — and  this,  too,  when  "  there  is,  upon 
the  grounds  of  the  institution,  a  never-failing  spring  of  most  excellent  water, 
yielding  a  quantity  sufficient,  during  the  greater  part  of  the  year,  to  supply  their 
daily  wants." 

"  I  should  not  feel  that  I  had  laid  the  matter  fully  before  your  Board  if  I 
omitted  to  speak  of  the  quality  of  the  water  thus  scantily  and  irregularly  and 
expensively  furnished.  I  have  already,  at  different  times,  drawn  your  attention 
to  the  colour,  and  I  may  say  the  consistency  of  the  article,  as  it  has  appeared  in 
the  reservoirs.  You  have;  found  it  holding  in  suspension  so  much  foreign  matter 
as  to  render  it  opaque.  This  matter  consists  of  the  natural  debris  which  a  rapid 
Stream,  supplied  by  many  feeders  and  flowing  through  a  soil  of  various  compo- 
sition, always  carries  with  it.  To  this  is  added  a  miscellaneous  mass  of  impurity 
poured  into  it  by  a  great  variety  of  manufacturing  establishments.  The  mixture 
is  at  times  disgusting  to  the  sight  and  smell,  and  its  effects  equally  offensive  in 


/ 

1863.]  American  Insane  Hospital  Reports,  155 

the  laundry  and  the  kitchen.  The  precipitation  of  vegetable  matter  in  the  large 
boilers,  as  you  are  aware,  will  probably  soon  create  a  necessity  for  expensive 
repairs,  by  the  '  burning'  and  '  scaling'  of  the  iron  where  most  exposed  to  the 
action  of  the  fire." 

7.  At  the  Longview  Asylum,  those  parts  of  the  numerical  history  of  the  hos- 
pitals which  we  are  accustomed  regularly  to  reproduce,  are  represented  by  the 
following  figures : — 

Men.    Women.  Total. 


Patients,  November  1st,  1860  . 
Admitted  in  course  of  the  year  . 

Whole  number  

Discharged,  including  deaths 
Eemaining,  November  1st,  1861 
Of  the  discharged,  there  were  cured  . 
Died  


151 

183 

334 

111 

76 

187 

262 

259 

521 

96 

68 

164 

166 

191 

357 

67 

48 

115 

12 

14 

26 

Died  from  phthisis,  10 ;  general  paralysis,  5 ;  maniacal  exhaustion,  4 ;  senile 
debility,  2  ;  apoplexy,  2  ;  epilepsy,  1 ;  marasmus,  1 ;  cerebral  congestion.  1. 

"  Quite  a  large  number  died  of  diseases  not  directly  connected  with  their  in- 
sanity. Many  of  them  were  very  old  patients  ;  half  of  them  had  been  in  asylums 
more  than  ten  years  ;  some  were  inmates  of  the  lunatic  department  of  the  Com- 
mercial Hospital,  Cincinnati,  as  far  back  as  1832,  beyond  which  there  are  no 
records  of  that  institution. 

"  There  has  been  but  little  sickness  in  the  house  originatiug  after  the  admis- 
sion of  the  patients  ;  and  there  has  been  entire  freedom  from  epidemics,  or  dis- 
eases of  any  kind  depending  upon  general  causes,  such  as  location,  &c.  In  one 
respect  this  has  been  quite  remarkable,  although  something  similar  has  been 
observed  in  other  asylums.  Intermittent  fever  has  prevailed  extensively  in  the 
immediate  neighbourhood  of  the  institution,  and  has  attacked  several  of  the 
residents,  including  the  superintendent ;  but  not  one  of  the  insane  has  been  at 
all  affected  by  it. 

"  Of  the  whole  number  of  recoveries,  ninety-two  were  of  patients  admitted  dur- 
ing the  year  ;  and  much  the  larger  portion  were  brought  to  the  asylum  within  a 
month  of  the  commencement  of  the  disease.  Of  those  who  had  been  labouring 
under  the  disease  one  year  or  more  before  being  brought  in,  but  little  over  one- 
fourth  recovered." 

While  treating  of  the  origin  of  insanity,  Dr.  Langdon,  judging  from  his  own 
patients  as  well  as  from  the  opinions  of  other  physicians,  says  "  by  far  the  greater 
number  of  cases  are  produced  by  causes  which  directly  depress  the  vital  ener- 
gies. This  is  farther  shown  by  the  condition  of  the  great  majority,  almost  all, 
of  the  patients  when  they  came  into  the  house.  -  Feeble,  depressed,  and  emaci- 
ated, they  require  tonics  and  supporting  treatment,  and  generally  show  improve- 
ment in  the  state  of  their  minds  as  their  physical  strength  improves." 

As  the  Longview  Asylum  is  intended  chiefly  for  paupers,  and  as  the  old  esta- 
blishment, for  which  it  is  the  substitute,  was  but  poorly  provided  with  the  means 
of  moral  treatment,  we  rejoice  in  the  assertion  that  "  during  the  year  there  have 
been  many  additions  to  our  means  of  recreation  and  amusement.  Among  these 
are  a  bowling  alley,  a  magic  lantern,  a  melodeon,  singing  birds,  flowers,  and 
pictures. 

The  annexed  paragraphs  are  worth  reading,  both  for  their  further  exposition 
of  the  moral  treatment,  and  for  the  discordance  of  some  of  the  opinions  therein 
expressed  with  the  opinions  of  some  others  of  the  superintendents  of  hospitals : — 

"  Once  in  each  week  we  have  had  dancing  parties,  which  have  been  attended 
by  a  large  number  of  the  patients  with  evident  benefit,  in  some  cases  increasing 
their  cheerfulness,  exciting  more  interest  in  external  matters,  withdrawing  them 
from  the  contemplation  or  their  morbid  fancies,  and  stimulating  their  minds  to 
activity  in  a  new  direction.  These  parties  are  very  much  enjoyed,  and  antici- 
pated with  great  pleasure  by  all  the  patients  who  are  able  to  attend  them  ;  fur- 
nish material  for  conversation  both  before  and  after,  and  seem  to  be  generally 
productive  of  good.    The  same  may  be  said  of  concerts,  which  we  occasionally 


156 


Bibliographical  Notices. 


[Jan. 


have  of  an  informal  kind — music,  both  instrumental  and  vocal,  having  a  quieting 
effect  at  the  same  time  that  it  tends  to  break  up  their  habitual  morbid  train  of 
thought. 

"  Religious  services  have  been  discontinued  for  a  long  time,  as  they  do  not 
appear  to  have  any  beneficial  effect,  and  sometimes  do  positive  harm.  The  re- 
ligious education  and  belief  of  the  patients  differs  so  widely  that  it  is  almost  im- 
possible so  to  arrange  it  as  not  to  offend  and  excite  some  portion  of  them  when 
any  religious  services  are  held.  We  have  Jews  and  Christians,  Protestants  and 
Catholics.  Spiritualists  and  Infidels  in  the  house,  all  as  firmly  convinced  of  the 
truth  of  their  own  particular  belief  and  as  intolerant  of  any  other  as  if  they  were 
perfectly  rational,  and  any  appearance  of  favouring  one  or  the  other  form  excites 
prejudice  and  destroys  that  trust  and  confidence  which  is  of  so  much  benefit  in 
the  treatment  of  the  insane. 

"  It  can  hardly  be  claimed  that  there  is  a  necessity  for  religious  exercises 
among  persons  not  able  to  transact  the  ordinary  business  of  life  in  consequence 
of  their  disorder  of  mind.  Nor  would  it  be  easy  to  find  a  person  so  peculiarly 
gifted  as  to  be  able  to  conduct  such  exercises  in  a  manner  that  would  at  least 
do  no  harm. 

"  For  reasons  somewhat  similar,  no  funeral  services  are  had  at  the  institution, 
the  mere  knowledge  of  a  death  taking  place  is  of  itself  depressing,  and  has  a 
pernicious  influence  on  many  of  the  inmates,  and  to  impress  it  on  their  minds 
by  funeral  services  seems  to  me  would  be  productive  of  only  bad  results." 

We  have  taken  the  liberty  to  italicise  one  clause  in  this  extract.  Of  the  521 
patients  treated  in  the  course  of  the  year,  only  163  were  natives  of  the  Ameri- 
can continent,  while  353  were  Europeans. 

8.  The  general  items  of  the  register  of  the  New  Hampshire  Asylum,  for  the 
year  terminating  with  the  close  of  April,  1862,  are  as  follows : — 

Men.   Women.  Total. 

Patients  at  the  beginning  of  the  year 
Admitted  in  course  of  the  year 

Whole  number  

Discharged,  including  deaths 
Remaining  at  the  end  of  the  year 
Of  the  discharged,  there  were  cured 
Died  


88  10S  196 

45  41  86 

133  149  282 

45  49  94 

88  100  188 

20  21  41 

10  3  13 


Died  with  epilepsy,  5;  "dropsy  from  disease  of  heart,"  1;  "disease  of  the 
heart  originating  in  rheumatism,"  1 ;  chronic  pleurisy,  1 ;  exhaustion  of  acute 
mania,  1 ;  general  paralysis,  1 ;  organic  disease  of  the  brain,  1 ;  exhaustion  of 
chronic  insanity,  2. 

"  Much  sewing,  knitting,  and  similar  work  has  been  done  by  the  female  pa- 
tients, which  has  a  second  value,  great,  though  less  than  that  accruing  to  the 
labourer  herself.  This  is  emphatically  true  of  a  considerable  amount  of  sewing 
and  knitting  done  for  the  army.  No  occupation  has  seemed  to  afford  them  more 
unalloyed  pleasure,  than  that  done  for  the  noble  and  self-sacrificing  defenders  of 
our  country.'" 

The  hospital  having  completed  the  twentieth  year  of  its  operations,  the  occa- 
sion is  seized  by  Dr.  Bancroft  to  give  a  brief  sketch  of  its  history,  with  reflec- 
tions suggested  by  its  results.  From  the  account  of  the  proceedings  preliminary 
to  the  action  of  the  legislature  authorizing  the  construction  of  the  hospital,  we 
take  the  subjoined  extract. 

"  At  length  a  call  was  made  on  the  several  towns  for  statistical  information 
as  to  the  number  and  condition  of  the  insane,  and  the  responses  to  this  call  early 
confirmed  their  previous  convictions.  Returns  were  received  from  161  towns. 
Of  these  only  20  were  without  insane  persons.  In  the  balance  of  the  towns 
there  were  312  insane,  and  of  these  152  were  entirely  a  public  charge;  160  being 
independent  of  public  charity.  Of  the  whole  number,  81;  or  nearly  26  per  cent., 
were  confined  in  cages,  jails,  close  rooms,  handcuffs,  or  the  like.  Insanity  had 
existed  in  these  individuals  for  periods  varying  from  a  few  weeks  to  sixty  years ; 
the  average  of  the  whole  being  about  thirteen  and  one-half  years.    In  the  report 


1863.] 


Holmes,  Border  Lines  of  Medical  Science. 


151 


of  the  committee  deputed  to  collect  these  facts,  made  to  the  Legislature  in  1836, 
they  declare  'that  the  horrors  of  the  present  condition  of  the  insane  are  far  from 
having  been  exaggerated.' " 

The  following  selections  are  from  the  remaining  portion  of  this  section  of  the 
report. 

"  The  theory  and  policy  of  the  guardians,  as  well  as  the  successive  physicians, 
has  been  to  reduce  the  difference  between  the  wards  of  the  Asylum  and  a  well- 
regulated  household,  to  the  lowest  point  consistent  with  safety,  and  the  integrity 
of  the  best  curative  agencies." 

"  Even  in  the  wreck  of  reason  and  responsibility,  nature  has  kindly  provided 
that  the  human  being  need  not  be  wholly  a  wreck.  Such  is  the  organization, 
that,  like  an  automatic  machine,  when  the  intelligent,  directing  mind  is  cast 
from  its  supremacy,  still,  under  a  law  of  habit,  if  the  individual  can  be  under  the 
influence  of  another  mind  to  keep  him  in  motion,  he  will  follow  to  a  great  extent 
the  routine  of  ordinary  life,  when,  without  this  exterior  influence,  he  would  sub- 
side into  stupid  inaction,  and  fall  under  the  direction  of  the  mere  animal  instincts. 
It  is  by  availing  themselves  of  this  principle,  that  asylums,  in  cases  of  the  in- 
curable, are  able  to  transform  what  would  otherwise  be  little  more  than  exist- 
ence into  a  life  possessing  many  rational  occupations  and  enjoyments." 

"  Of  the  1927  who  have  been  received  into  the  Asylum,  841  have  been  restored 
to  mental  soundness.  *  *  *  It  is  not  easy  to  calculate  the  value  of  the  re- 
storation to  society  of  this  considerable  number  of  insane,  or  to  estimate  the 
amount  of  pain  and  sorrow  mitigated  or  relieved  by  their  escape  from  a  fate 
more  to  be  dreaded  than  death.  But  whatever  society,  the  domestic  circle,  or 
bleeding  hearts,  may  realize  from  these  restorations,  it  is  of  small  account  com- 
pared with  the  reinstating  of  reason  in  the  mind  from  which  it  had  been  de- 
throned ;  the  restoring  of  delicate  sentiments  and  affections,  the  perversion  of 
which  had  changed  the  sweets  of  life  to  bitterness." 

The  first  Superintendent  of  this  Institution  was  Dr.  George  Chandler,  after- 
wards Superintendent  of  the  Massachusetts  State  Hospital,  at  Worcester,  and 
now  a  resident  of  that  city,  but  retired  from  active  duty  in  the  profession.  His 
successors  have  been  Dr.  Andrew  McFarland,  now  having  charge  of  the  State 
Hospital  of  Illinois,  Dr.  John  E.  Tyler,  now  at  the  head  of  the  McLean  Asylum, 
and  Dr.  J.  P.  Bancroft,  the  present  incumbent.  P.  E. 


Art.  XXII. — Border  Lines  of  Knowledge  in  some  Provinces  of  Medical  Science. 
An  Introductory  Lecture,  delivered  before  the  Medical  Class  of  Harvard  Uni- 
versity, November  6th,  1861.  By  Oliver  Wendell  Holmes,  M.D.,  Parkman 
Professor  of  Anatomy  and  Physiology.  Ticknor  &  Fields :  Boston,  1862. 
8vo.  pp.  80. 

Introductory  Lectures  are,  for  the  most  part,  froth  upon  the  ale  of  science. 
As  the  bitterness  and  exhilarating  influences  of  the  beverage  are  foreshadowed 
in  the  taste  and  effervescence  of  the  foam,  so  the  nature  and  the  power  of  the 
science  are  often  exhibited  in  that  first  lecture  which  introduces  it  to  the  atten- 
tion of  the  student.  The  drinker  looks  with  pleasing  anticipations  upon  the 
bubbles  as  they  rise  in  his  glass,  and  the  student  is  filled  with  bright  expecta- 
tions by  the  sparkling  thoughts  of  the  introductory  as  they  fall  from  the  lips  of 
the  enthusiastic  professor.  But  as  the  evanescent  foam  is  blown  lightly  away 
and  forgotten  even  before  the  cup  is  drained,  so  the  ephemeral  introductory  is 
remembered  no  longer  than  the  hour  in  which  it  was  pronounced.  The  specimen, 
now  before  us,  of  this  peculiar  kind  of  literature,  has  been  clothed  in  a  more 
enduring  garb  than  is  generally  awarded  to  its  fellows,  and  may  possibly  eke 
out  a  longer  existence.  It  is  written  in  a  lively  and  attractive  manner,  and 
abounds  iu  bold,  dogmatic  statements,  which  are,  occasionally,  more  satirical, 
however,  than  truthful. 


158 


Bibliographical  Notices. 


[Jan. 


The  object  and  the  scope  of  the  lecture  are  thus  happily  told  : — 
"  Science  is  the  topography  of  ignorance.    From  a  few  elevated  points  we 
triangulate  vast  spaces,  enclosing  infinite  unknown  details.7  We  cast  the  lead, 
and  draw  up  a  little  sand  from  abysses  we  shall  never  reach  with  our  dredges. 

"  The  best  part  of  our  knowledge  is  that  which  teaches  us  where  knowledge 
leaves  off  and  ignorance  begins.  Nothing  more  clearly  separates  a  vulgar  from 
a  superior  mind,  than  the  confusion  in  the  first  between  the  little  that  it  truly 
knows,  on  the  one  hand,  and  what  it  half  knows  and  what  it  thinks  it  knows,  on 
the  other. 

"  That  which  is  true  of  every  subject  is  especially  true  of  the  branch  of  know- 
ledge which  deals  with  living  beings.  Their  existence  is  a  perpetual  death  and 
reanimation.  Their  identity  is  only  an  idea,  for  we  put  off  our  bodies  many 
times  during  our  lives,  and  dress  in  new  suits  of  bones  and  muscles.1 

"  <  Thou  art  not  thyself  ; 
For  thou  exist'st  on  many  a  thousand  grains 
That  issue  out  of  dust.' 

If  it  is  true  that  we  understand  ourselves  but  imperfectly  in  health,  it  is  more 
signally  manifest  in  disease,  where  natural  actions  imperfectly  understood,  dis- 
turbed in  an  obscure  way  by  half-seen  causes,  are  creeping  and  winding  along  in 
the  dark  toward  their  destined  issue,  sometimes  using  our  remedies  as  safe 
stepping-stones,  occasionally,  it  may  be,  stumbling  over  them  as  obstacles. 

"  I  propose  in  this  lecture  to  show  you  some  points  of  contact  between  our 
ignorance  and  our  knowledge  in  several  of  the  branches  upon  the  study  of  which 
you  are  entering.  I  may  teach  you  a  very  little  directly,  but  I  hope  much  more 
from  the  trains  of  thought  I  shall  suggest.  Do  not  expect  too  much  ground  to 
be  covered  in  this  rapid  survey.  Our  task  is  only  that  of  sending  out  a  few 
pickets  under  the  starry  flag  of  science  to  the  edge  of  that  dark  domain  where 
the  ensigns  of  the  obstinate  rebel,  Ignorance,  are  flying  undisputed.  We  are 
not  making  a  reconnoissance  in  force,  still  less  advancing  with  the  main  column. 
But  here  are  a  few  roads  along  which  we  have  to  march  together,  and  we  wish 
to  see  clearly  how  far  our  lines  extend,  and  where  the  enemy's  outposts  begin." 

The  salient  points  of  the  sciences  of  chemistry,  human  and  pathological  ana- 
tomy, microscopy,  physiology,  medicine,  and  surgery,  are  made  to  pass  before 
the  reader  in  cursory  but  piquant  review.  In  the  course  of  his  remarks  upon 
chemistry,  Dr.  Holmes  takes  occasion  to  dwell  for  a  moment  upon  the  fruitless- 
ness  of  attempting  to  explain  the  essential  nature  of  chemical  affinities  and 
crystalline  types,  and  of  determining  the  identity  of  the  substances  with  which 
we  deal,  and  the  laws  of  their  combination.  In  this  connection  he  reminds  us 
of  the  allotropic  conditions  of  sulphur'and  phosphorus,  and  says: — 

"  These  facts  of  allotropism  have  some  corollaries  connected  with  them  rather 
startling  to  us  of  the  nineteenth  century.  There  may  be  other  transmutations 
possible  besides  those  of  phosphorus  and  sulphur.  When  Dr.  Prout,  in  1840, 
talked  about  azote  and  carbon  being  'formed'  in  the  living  system,  it  was  looked 
upon  as  one  of  those  freaks  of  fancy  to  which  philosophers,  like  other  men,  are 
subject.  But  when  Professor  Faraday,  in  1851,  says,  at  a  meeting  of  the  British 
Association,  that  'his  hopes  are  in  the  direction  of  proving  that  bodies  called 
simple  were  really  compounds,  and  may  be  formed  artificially  as  soon  as  we  are 
masters  of  the  laws  influencing  their  combinations' — when  he  comes  forward  and 
says  that  he  has  tried  experiments  at  transmutation,  and  means,  if  his  life  is 
spared,  to  try  them  again — how  can  we  be  surprised  at  the  popular  story  of 
1801,  that  Louis  Napoleon  has  established  a  gold-factory  and  is  glutting  the 
mints  of  Europe  with  bullion  of  his  own  making?" 

As  we  write  there  lies  at  our  elbow  a  curious  book  from  the  pen  of  Dr.  Louis 
Figuier,  "  Agrege  de  chimie  a  l'Ecole  de  Pharmacie  de  Paris."  The  title  of  this 
book  runs  thus:  "L'Alchimie  et  les  Alchimistes  ;  Essai  historique  et  critique 
sur  la  Philosophte  herme'tique."    From  its  concluding  pages  we  learn  that  seve- 


1  "  Occasio  enim  prseceps  est  propter  artis  materiani,  dico  autem  corpus,  quod 
continue  fluit  et  momento  temporis  transinutatur." — Galen,  Com.  in  Aphorism. 
Hippoo  I.  1. 


1863.] 


Holmes,  Border  Lines  of  Medical  Science. 


159 


ral  memoirs  were  read  in  1853  and  1854  before  the  Academy  of  Sciences,  of  Paris, 
the  object  of  which  was  to  show  that  "  les  me'taux  ne  sont  pas  des  corps  simples, 
mats  bien  des  corps  composes,"  and  that  "  la  production  artificielle  des  me'taux 
prScieux  est  possible,  est  un  fait  ave're'."  The  author  of  these  memoirs  is  C. 
Theodore  Tiffereau,  "  ancien  eleve  et  pr6parateur  de  chimie  a  l'ecole  pr6para- 
toire  de  Nantes,"  who  boldly  said  to  the  Academy  "  J'ai  dtcouvert  lemoyen  de 
produire  de  Vor  artificiel,  fai  fait  de  Vor,"  and  endeavoured,  by  a  series  of 
experiments,  to  convince  his  hearers  that  he  spoke  the  truth,  and  was  deceiving 
neither  himself  nor  them.  When  the  artificial  production  of  gold  is  thus  gravely 
announced  at  a  sitting  of  the  world-renowned  Parisian  Academy,  as  an  accom- 
plished fact,  we  need  not,  indeed,  be  surprised  at  the  story  of  Louis  Napoleon's 
gold-factory. 

As  we  follow  Dr.  Holmes  through  his  "  Border  Lines,"  we  meet  with  passages, 
here  and  there,  which  we  are  strongly  tempted  to  transfer  to  our  pages.  The 
following  passing  thrust  at  the  quasi-science,  phrenology,  aptly  illustrates  the 
racy  style  in  which  the  whole  lecture  is  written  : — 

"  By  the  manner  in  which  I  spoke  of  the  brain,  you  will  see  that  I  am  obliged 
to  leave  phrenology  sub  Jove — out  in  the  cold — as  not  one  of  the  household  of 
science.  I  am  not  one  of  its  haters ;  on  the  contrary,  I  am  grateful  for  the  in- 
cidental good  it  has  done.  I  love  to  amuse  myself  in  its  plaster  Golgothas,  and 
listen  to  the  glib  professor,  as  he  discovers  by  his  manipulations 

'  All  that  disgraced  my  betters  met  in  me.' 

I  loved  of  old  to  see  square-headed,  heavy-jawed  Spurzheim  make  a  brain  flower 
out  into  a  corolla  of  marrowy  filaments,  as  Vieussens  had  done  before  him,  and 
to  hear  the  dry-fibred  but  human-hearted  George  Combe  teach  good  sense  under 
the  disguise  of  his  equivocal  system.  But  the  pseudo-sciences,  phrenology  and 
the  rest,  seem  to  me  only  appeals  to  weak  minds  and  the  weak  points  of  strong 
ones.  There  is  a  pica  or  false  appetite  in  many  intelligences  ;  they  take  to  odd 
fancies  in  place  of  wholesome  truth,  as  girls  gnaw  at  chalk  and  charcoal.  Phre- 
nology juggles  with  nature.  It  is  so  adjusted  as  to  soak  up  all  evidence  that 
helps  it,  and  shed  all  that  harms  it.  It  crawls  forward  in  all  weathers,  like 
Richard  Edgeworth's  hygrometer.  It  does  not  stand  at  the  boundary  of  our 
ignorance,  it  seems  to  me,  but  is  one  of  the  will-o'-the-wisps  of  its  undisputed 
central  domain  of  bog  and  quicksand.  Yet  I  should  not  have  devoted  so  many 
words  to  it,  did  I  not  recognize  the  light  it  has  thrown  on  human  actions  by  its 
study  of  congenital  organic  tendencies.  Its  maps  of  the  surface  of  the  head  are, 
I  feel  sure,  founded  on  a  delusion,  but  its  studies  of  individual  character  are 
always  interesting  and  instructive." 
Of  homoeopathy,  he  writes  : — 

"It  has  unquestionably  helped  to  teach  wise  people  that  nature  heals  most 
diseases  without  help  from  pharmaceutic  art,  but  it  continues  to  persuade  fools 
that  art  can  arrest  them  all  with  its  specifics." 

And  again,  in  reference  to  changes  in.  medical  opinion  and  practice  : — 
"  The  practice  of  medicine  has  undergone  great  changes  within  the  period  of 
my  own  observation.  Yenesection,  for  instance,  has  so  far  gone  out  of  fashion, 
that,  as  I  am  told  by  residents  of  the  New  York,  Bellevue,  and  the  Massachu- 
setts General  Hospitals,  it  is  almost  obsolete  in  these  institutions,  at  least  in 
medical  practice.1  The  old  Brunonian  stimulating  treatment  has  come  into 
vogue  again  in  the  practice  of  Dr.  Todd  and  his  followers.  The  compounds  of 
mercury  have  yielded  their  place  as  drugs  of  all  work,  and  specifics  for  that  very 
frequent  subjective  complaint,  nescio  quid  faciam — to  compounds  of  iodine.2 
Opium  is  believed  in,  and  quinine,  and  '  rum,'  using  that  expressive  monosyllable 


1  A  similar  change  has  taken  place  also  in  English  surgical  practice.  Sir  W. 
Napier  speaks  of  "  that  inveterate  use  of  the  lancet,  which  disgraced  the  surgery 
of  the  times" — the  early  years  of  this  century.  Life  and  Opinions  of  Sir  Charles 
James  Napier  (London,  1857),  vol.  i.  p.  153. 

2  Sir  Astley  Cooper  has  the  boldness — or  honesty — to  speak  of  medicines  which, 
"  are  given  as  much  to  assist  the  medical  man  as  his  patient."  Lectures  (London, 
1832),  p.  14. 


160 


Bibliographical  Notices. 


[Jan. 


to  mean  all  alcoholic  cordials.  If  Moliere  were  writing  now,  instead  of  saig- 
nare,  pwrgare,  and  the  other,  he  would  be  more  like  to  say,  Stimulare,  opium, 
dare  et  potassio-iodizare. 

••  What  is  the  meaning  of  these  perpetual  changes  and  conflicts  of  medical 
opinion  and  practice,  from  an  early  antiquity  to  our  own  time?  Simply  this  : 
all  '  methods'  of  treatment  end  in  disappointment  of  those  extravagant  expecta- 
tions which  men  are  wont  to  entertain  of  medical  art.  The  bills  of  mortality 
are  more  obviously  affected  by  drainage,  than  by  this  or  that  method  of  practice. 
The  insurance  companies  do  not  commonly  charge  a  different  percentage  on  the 
lives  of  the  patients  of  this  or  that  physician.  In  the  course  of  a  generation,  more 
or  less,  physicians  themselves  are  liable  to  get  tired  of  a  practice  which  has  so 
little  effect  upon  the  average  movement  of  vital  decomposition.  Then  they  are 
ready  for  a  change,  even  if  it  were  back  again  to  a  method  which  has  already 
been  tried,  and  found  wanting. 

"  Our  practitioners,  or  many  of  them,  have  got  back  to  the  ways  of  old  Dr. 
Samuel  Danforth,  who,  as  it  is  well  known,  had  strong  objections  to  the  use  of 
the  lancet.  By  and  by  a  new  reputation  will  be  made  by  some  discontented 
practitioner,  who,  tired  of  seing  patients  die  with  their  skins  full  of  whiskey  and 
their  brains  muddy  with  opium,  returns  'to  a  bold  antiphlogistic  treatment,  and 
has  the  luck  to  see  a  few  patients  of  note  get  well  under  it.  So  of  the  remedies 
which  have  gone  out  of  fashion  and  been  superseded  by  others.  It  can  hardly 
be  doubted  that  they  will  come  into  vogue  again,  more  or  less  extensively,  under 
the  influence  of  that  irresistible  demand  for  change  just  referred  to. 

"  Then  will  come  the  usual  talk  about  a  change  in  the  character  of  disease, 
which  has  about  as  much  meaning  as  that  concerning  1  old-fashioned  snow- 
storms.' 'Epidemic  constitutions'  of  disease  mean  something,  no  doubt;  a 
great  deal  as  applied  to  malarious  affections ;  but  that  the  whole  type  of  diseases 
undergoes  such  changes  that  the  practice  must  be  reversed  from  depleting  to 
stimulating,  and  vice  versa,  is  much  less  likely  than  that  the  methods  of  treat- 
ment go  out  of  fashion  and  come  in  again." 

In  these  very  positive  assertions  of  our  author,  error  and  truth,  we  think,  are 
mingled  together.  That  much  mischief  has  resulted  from  the  blind  and  over- 
weening confidence  of  this  or  that  physician  in  such  a  drug,  or  such  a  method  of 
medication,  cannot  be  gainsaid,  but  that  the  great  radical  changes  which  medical 
treatment  in  certain  classes  of  disease  has  undergone  from  time  to  time,  is  the  re- 
sult merely  of  fashion  or  the  caprice  of  practitioners  of  medicine,  is  wholly  inadmis- 
sible. Such  an  opinion  is  in  itself  an  insult,  not  merely  to  the  therapeutic  skill, 
but  also  to  the  good  sense  and  integrity  of  every  physician  who  follows  his  noble 
calling  as  a  conscientious  man,  and  an  earnest  and  enlightened  student.  The 
professed  wit  will  sacrifice  his  best  friend  rather  than  forego  the  utterance  of  a 
jest.  Here  and  there  in  the  writings  of  our  author,  the  evidence  is  patent  that 
the  opportunity  to  enunciate  some  brilliant  expression  or  mirth-provoking  com- 
parison, has  overcome  the  dictum  of  sober  judgment,  and  ignored  the  very  facts 
which  falsify  the  witticism.  When  Dr.  Holmes  tells  us  that  the  "usual  talk" 
about  a  change  in  the  character  of  disease  has  as  much  meaning  as  that  con- 
cerning "  old-fashioned  snow-storms,"  he  is  doubly  unfortunate,  inasmuch  as  the 
facts  of  the  historical  record,  relating  both  to  disease  and  climate,  are  all  against 
him.  Let  him  refer,  on  the  one  hand,  to  the  chapter  on  physical  climate,  in 
Milner's  "  Gallery  of  Nature,"  and  on  the  other,  to  the  closing  chapters  of  Dr. 
Edward  Smith's  admirable  and  original  treatise  on  "  Health  and  Disease,"  no- 
ticed by  us  in  the  preceding  number  of  this  journal.  Other  works,  bearing  upon 
this  subject,  we  might  readily  cite,  but  the  two  mentioned  are  just  at  hand,  and 
they  contain  facts  and  arguments  sufficient  to  refute  the  idea  so  lightly,  and, 
must  we  say  it,  so  thoughtlessly  advanced  by  our  author. 

As  an  eminent  medical  teacher  occupying  a  high  position,  and  as  a  writer  of 
great  ability  and  weight,  Dr.  Holmes  should,  as  he  is  well  able  to  do,  supply  his 
hearers  with  the  good  and  wholesome  wheat  of  science  from  which  the  chaff  of 
error  has  been  carefully  and  patiently  winnowed.  J.  A.  M. 


1863.]     Jarvis,  Sanitary  Condition  of  the  Army  of  the  IT.  S. 


Art.  XXIII. —  The  Sanitary  Condition  of  the  Army  of  the  United  States.  By 
Edward  Jarvis,  M.  D.,  of  Dorchester,  Mass.  8vo.  pp.  36.  From  the  Atlan- 
tic Monthly  for  October,  1862. 

The  efficiency  of  an  army  in  the  field  will  depend  as  much  upon  the  health, 
bodily  vigour,  and  vital  energy  of  the  soldiery  composing  it,  as  upon  the  excel- 
lency of  its  discipline,  the  correctness  of  its  drill,  and  the  military  capacity  of 
its  officers.  Hence,  in  order  to  have  a  strong  and  effective  army,  ready  at  any 
moment  to  accomplish  whatever  enterprise  it  may  be  employed  to  execute,  it 
is  not  only  requisite  that  it  be  composed  of  a  sufficient  number  of  men,  but, 
also,  that  each  one  of  these  possess  in  himself  the  largest  amount  of  force,  and 
vigour,  and  energy,  based  upon  the  most  perfect  health,  of  which  the  human 
organism  is  capable.  This  fact  is  to  be  kept  steadily  in  view  in  the  very  first 
steps  taken  for  the  formation  of  an  army.  The  men  who  are  to  compose  it 
should  all  be  picked  men :  selected  from  out  the  community  because  of  their 
particular  adaptedness  for  the  business  of  war.  The  army  will  then  be  made 
up,  in  the  first  instance,  of  a  soldiery  in  the  fulness  of  strength  and  efficiency. 
It  will  commence  with  the  possession  of  a  much  higher  average  of  health  and 
vigour,  a  far  greater  power  of  endurance,  of  activity,  and  of  resistance  to  the 
ordinary  causes  of  disease  than  is  to  be  found  in  the  mass  of  men  of  the  same 
ages  in  civil  life.  Now,  it  is  not  only  necessary  that  the  army  should  possess, 
at  its  organization,  this  fulness  of  health  and  efficiency  of  power  in  those  who 
compose  it,  but  that  this  very  state  of  things  be  sustained,  as  far  as  it  is  possible, 
during  the  entire  period  it  remains  in  commission — at  all  times  and  in  all  places, 
throughout  weeks  and  months  of  labour  and  privation— in  the  face  of  all  the 
numerous  causes  which  are  continually  in  action  to  cause  a  deterioration  of  the 
bodily  force  and  vigour — a  prostration  of  the  strength,  and  energy,  and  capacity 
for  endurance  of  the  soldier  in  actual  service. 

Admit  the  truth  of  the  foregoing  positions,  and  their  truth  is  almost  self- 
evident,  and  we  can  readily  perceive  the  immense  importance  of  an  intimate 
acquaintance,  on  the  part  of  the  army  surgeon,  with  sanitary  science,  in  its 
application  to  the  condition  of  the  soldier  in  time  of  peace,  in  camp,  or  upon  the 
field  of  battle  ;  that  he  knows  what  to  do  and  how  to  act  in  order  that  the  entire 
army  may  be  placed,  so  far  as  is  practicable,  under  the  circumstances  which  are 
best  adapted  to  keep  up  the  necessary  fund  of  vital  stamina  and  activity  in  the 
soldiery  who  compose  it. 

The  hygiene  of  an  army,  especially  when  in  the  field,  differs  in  many  respects 
from  the  hygiene  of  civil  life.  The  soldier  is  liable  to  the  influence  of  most,  if 
not  all,  of  those  causes  of  vital  depression  and  disease  which  threaten  the 
civilian,  requiring  in  the  former,  as  in  the  latter,  to  maintain  the  full  standard 
of  health  and  vigour,  the  same  attention  to  the  air  he  breathes,  the  food  he 
eats,  the  water  he  drinks,  the  clothes  he  wears ;  the  same  attention  to  cleanli- 
ness, personal  and  domestic,  and  to  the  means  of  shelter  from  cold  and  excessive 
heat,  the  rays  of  the  summer's  sun  and  the  wintry  storm.  In  addition  to  these, 
however,  the  soldier  is  exposed  to  other  morbific  and  depressive  influences 
peculiar  to  military  life,  or  consequent  upon  the  change  in  his  habits  and  modes 
of  life  caused  by  his  leaving  domestic  comforts  for  the  discomforts  of  the  tent, 
the  march,  and  the  bivouac. 

"  The  business  of  war  is  not,"  as  Dr.  Jarvis  very  correctly  remarks,  "  con- 
stant and  permanent,  like  the  pursuits  of  peace.  It,  therefore,  comes  to  most 
managers  as  a  new  and  unfamiliar  work,  to  which  they  can  bring  little  or  no 
acquaintance  from  experience.  They  enter  upon  untried  ground  with  imperfect 
knowledge  of  its  responsibilities  and  dangers,  and  inadequate  conceptions  of  the 
materials  and  powers  with  which  they  are  to  operate.  They,  therefore,  make 
many,  and  some  very  grave  mistakes,  every  one  of  which,  in  its  due  proportion, 
is  doubly  paid  for,  in  drafts  on  the  nation's  treasury  and  on  the  soldier's  vital 
capital,  neither  of  which  is  ever  dishonoured. 

"  Military  life  is  equally  new  to  the  soldier,  for  which  none  of  his  previous 
education  or  experience  has  fitted  him.  He  has  had  his  mother,  wife,  sister, 
No.  LXXXIX.— Jan.  1863.  11 


1G2 


Bibliographical  Notices. 


[Jan. 


or  other  housekeeper,  trained  and  appointed  for  the  purpose,  to  look  after  his 
nutrition,  his  clothing,  his  personal  comfort,  and,  consequently,  his  health. 
These  do  not  come  without  thought  and  labour.  The  domestic  administration 
of  the  household  and  the  care  of  its  members  require  as  much  talent,  intelligence, 
and  discipline  as  any  of  the  ordinary  occupations  of  men.  Throughout  the 
civilized  world,  this  responsibility  and  the  labour  necessary  for  its  fulfilment 
absorb  a  large  portion  of  the  mental  and  physical  power  of  women. 

"  When  the  new  recruit  enters  the  army,  he  leaves  all  this  care  and  protection 
behind,  but  finds  no  substitute,  no  compensation  for  its  loss  in  his  new  position. 
The  government  supposes  either  that  this  is  all  unnecessary,  or  that  the  man  in 
arms  has  an  inspired  capacity  or  an  instinctive  aptitude  for  self-care  as  well  as 
for  labour,  and  that  he  can  generate  and  sustain  physical  force  as  well  as  expend 
it.  But  he  is  no  more  fitted  for  this,  by  his  previous  training  and  habits,  than 
his  mother  and  wife  are  for  making  shoes  or  building  houses  by  theirs.  Never- 
theless, he  is  thrown  upon  his  own  resources  to  do  what  he  may  for  himself. 
The  army  regulations  of  the  United  States  say :  '  Soldiers  are  expected  to  pre- 
serve, distribute,  and  cook  their  own  subsistence;'  and  most  other  governments 
require  the  same  of  their  men.  Washing,  mending,  sweeping,  all  manner  of 
cleansing,  arrangement  and  care  of  whatever  pertains  to  clothing  and  house- 
keeping, come  under  the  same  law  of  proscription  or  necessity.  The  soldier 
must  do  those  things,  or  they  will  be  left  undone.  He  who  has  never  arranged, 
cared  for,  or  cooked  his  own  or  any  other  food  ;  who  has  never  washed,  mended, 
or  swept,  is  expected  to  understand  and  is  required  to  do  these  for  himself,  or 
suffer  the  consequences  of  neglect.  The  want  of  knowledge  and  training  for 
these  purposes  makes  the  soldier  a  bad  cook  as  well  as  an  indiscreet,  negligent, 
and  often  a  slovenly  self-manager,  and  consequently  his  nutrition  and  his  per- 
sonal and  domestic  habits  are  neither  so  healthful  nor  so  invigorating  as  those 
of  men  in  civil  life ;  but  the  government  neither  thinks  of  this  deficiency  nor 
provides  for  it  by  furnishing  instruction  in  regard  to  this  new  responsibility  and 
these  new  duties,  nor  does  it  exercise  a  rigid  watchfulness  over  the  habits  of 
the  soldier  to  compel  them  to  be  as  good  and  as  healthful  as  they  may  be." 

Independently  of  the  large  amount  of  actual  disease  and  of  mortality  to  which 
armies  are  liable,  altogether  distinct  from  the  suffering,  decrepitude,  and  death 
caused  by  the  wounds  inflicted  by  the  weapons  of  the  enemy,  and  are  incurred 
alike  by  the  soldier  in  barracks,  in  cantonement,  and  in  encampment,  and  are 
as  certain  to  be  met  with,  though  never,  it  is  true,  to  the  same  extent  in  times 
of  peace  as  in  those  of  war — the  constitutional  vigour,  the  vital  force,  the  power 
of  endurance  and  resistance  of  the  soldier,  are  liable  to  become  depressed  during 
periods  of  actual  service,  and  from  causes  against  which  it  is  not  always  possible 
to  guard.  Among  these  causes  we  may  enumerate  the  want  of  a  regular  and 
adequate  supply  of  nutritious  and  easily  digested  food,  excessive  fatigue,  inter- 
ruption of  regular  nightly  repose,  exposure  without  adequate  protection  to  cold, 
heat,  and  wet,  and  often  to  malarious  influences,  with  numerous  other  privations, 
hardships,  and  discomforts  almost  unknown  in  civil  life. 

Much  of  the  disease  and  death  incident  to  the  military  life,  and  which  always 
reduce  to  a  great  extent  the  efficient  forces  of  an  army — causing  on  the  part  of 
the  government  heavy  expenditures,  and  repeated  drafts  upon  the  bone  and 
sinew — the  labouring  muscles  of  the  community,  in  order  to  keep  up  the  forces 
on  guard  and  in  the  field  to  their  requisite  strength,  is,  no  doubt,  due  in  great 
measure  to  preventable  causes.  Hence,  everything  which  has  a  tendency  to 
maintain  and  improve  the  sanitary  condition  of  an  army,  whether  in  peace  or 
during  war,  demands  the  serious  consideration  of  the  community,  of  the  govern- 
ment, and,  especially,  of  the  medical  and  other  officers  having  the  immediate 
health  of  the  soldiery  in  their  charge. 

From  what  has  been  already  accomplished  towards  sustaining  and  improving 
the  vigour,  health,  and  vital  energy  of  the  soldier,  it  is  very  evident  that,  as  the 
sanitary  laws  of  the  human  organism  become  better  understood  and  the  means 
for  their  practical  application  more  fully  developed  and  enforced,  many  of  the 
diseases  which  are  now  considered  as  in  some  degree  the  necessary  evils  of 
military  life,  may  be  effectually  prevented. 

The  sanitary  condition  of.  the  present  army  of  the  United  States,  it  is  con- 


1863.] 


J  a  cob  i,  Dentition  and  its  Derangements. 


163 


fessed,  is  more  favourable  than  that  of  any  army  of  former  times  or  of  other 
nations.  It  is  possible,  we  think,  to  raise  it  in  this  respect  to  a  still  more 
favourable  grade — to  reduce  still  further  the  danger  of  sickness  and  mortality 
in  our  soldiers,  to  bring  it  to  a  still  nearer  approximation  to  what  it  .  is  among 
men  of  the  same  age  and  stamina  of  constitution  in  civil  life.  There  is  no  reason 
whatever  why  in  a  time  of  peace  the  health  of  the  soldier  should  be  less  secure, 
or  his  life  in  greater  danger,  than  is  the  case  in  the  best  class  of  his  fellow-citizens 
at  home.  Even  during  a  period  of  actual  service  much  may  be  done  towards 
improving  the  sanitary  condition  of  the  army  by  placing  it  under  the  care  of 
surgeons  well  versed  in  the  science  of  health,  and  invested  with  sufficient  exe- 
cutive authority  to  have  executed  promptly  whatever  they  may  deem  necessary 
for  sustaining  the  health  and  vigour  of  the  soldiery,  so  far  as  these  measures 
can  be  carried  out  without  interfering  with  any  important  military  movement. 

The  essay  of  Dr.  Jarvis  is  one  adapted  to  interest  and  instruct  all  who  feel 
any  interest  in  the  well-being  and  efficiency  of  our  army.  It  presents  a  series 
of  reliable  statistics  drawn,  as  far  as  possible,  from  official  reports  in  reference 
to  the  ratio  of  sickness  and  mortality  of  military  bodies  in  peace  and  war  com- 
pared with  the  ratio  in  civil  life — and  the  source  and  extent  of  the  disease, 
resulting  in  invaliding  or  death,  to  which  they  are  liable.  He  examines  in  de- 
tail the  supposed  danger,  to  the  soldier ;  the  sickness  and  mortality  in  civil  life, 
compared  with  the  sickness  and  mortality  of  the  army  in  peace  and  in  war ; 
comparing  the  condition,  in  this  respect,  of  the  armies  of  the  United  States  in 
the  war  of  1812-14,  for  the  conquest  of  Mexico,  and  during  the  existing  rebel- 
lion, with  that  of  the  different  armies  of  Europe.  The  dangers  incident  -tor 
battles  upon  land  and  at  sea ;  the  want  of  sanitary  preparations  for  war  are 
inquired  into,  and  the  difference  between  the  conditions  of  civil  and  military  life 
pointed  out.  The  errors  committed  by  government  in  respect  to  its  ministra- 
tions for  the  protection  of  the  health  of  the  army  and  their  effects  are  con- 
sidered, and  a  general  notice  given  of  the  results  of  the  sanitary  reforms  already 
accomplished. 

The  subjects  of  which  the  author  treats,  it  is  evident,  are  throughout  well 
selected ;  all  his  facts  are  aptly  chosen  and  carefully  arranged  and  collated  ; 
while  his  general  conclusions  are  fairly  deducible  from  his  premises. 

D.  F.  C. 


Art.  XXIY. — Dentition  and  its  Derangements.  A  Course  of  Lectures  delivered 
in  the  New  York  Medical  College.  By  A.  Jacobi,  M.  D.,  Professor  of  Infantile 
Pathology  and  Therapeutics,  etc.    12mo.  pp.  172.    New  York  :  1862.  Bail- 
.liere  Brothers. 

The  leading  object  of  Dr.  Jacobi  in  this  little  volume  of  lectures,  is  to  prove 
that  dentition,  which  is  a  purely  physiological  process,  has  been  unjustly  accused 
of  being  the  cause  of  the  various  morbid  phenomena  which  so  frequently  occur 
in  conjunction  with  it.  The  several  morbid  conditions  so  frequently  observed 
during  the  period  of  teething,  according  to  Dr.  Jacobi,  have  an  origin  altogether 
independent  of  the  act  of  dentition.  In  the  establishment  of  this  thesis  he  is 
necessarily  led  into  an  examination  of  the  pathology  of  the  more  prominent  ail- 
ments of  infancy  and  childhood. 

Although  we  cannot  say  that  we  are  entirely  convinced  of  the  accuracy  of  all 
the  teachings  of  our  author,  we  nevertheless  have  been  particularly  interested 
in  the  perusal  of  his  lectures — as  well  those  which  discuss  the  physiological 
history  of  the  process  of  dentition,  as  the  series  especially  devoted  to  a  con- 
sideration of  the  nature  and  etiology  of  the  affections  which  usually  occur  in 
conjunction  with  the  cutting  of  the  teeth. 

It  is  very  evident  that  the  formation,  development,  and  protrusion  through 
the  gums  of  the  teeth,  are  purely  physiological  acts,  and,  like  all  other  normal 
acts  of  the  living  organism,  are  performed,  in  the  healthy  subject,  without  pain, 
inconvenience,  or  disturbance  of  any  kind.    That,  however,  in  children  who  are 


164 


Bibliographical  Notices. 


[Jan. 


morbidly  excitable — who  are  badly  nourished,  and  exposed  to  bad  hygienic  con- 
ditions generally,  who  are,  from  any  cause,  strongly  predisposed  to  the  occur- 
rence of  morbid  action,  the  process  of  dentition  may  become  the  exciting  cause 
of  disease  of  a  most  serious  character,  is  so  well  established  by  the  repeated 
observations  of  the  physicians  of  all  times  and  all  places,  that  the  fact  cannot 
be  gainsaid.  That  the  strictly  physiological  actions  of  either  of  the  organs  will, 
under  certain  predispositions  to  disease,  whether  in  the  system  at  large,  or  in 
the  organ  itself,  give  rise  to  pathological  results,  is  a  well  established  observa- 
tion; so,  also,  in  respect  to  dentition,  though,  under  conditions  strictly  normal, 
it  is  accomplished  without  suffering  or  disturbance  in  any  portion  of  the  system, 
it  is  very  certain  that,  when  there  is  present  a  proneness  to  disease,  teething  is 
often  attended  by  morbid  phenomena,  more  or  less  intense — and  thus  may  be- 
come the  exciting  cause  of  some  serious  malady. 

It  is  unquestionably  true  that  a  large  number,  we  would  say  the  greater 
majority  of  infants  cut  their  teeth  without  any  bad  symptoms — it  is  equally  true 
that  the  morbid  phenomena  which  may  be  observed  to  precede  or  accompany 
the  protrusion  of  the  teeth,  are  not  in  every  case  dependent  directly  or  remotely 
upon  the  process  of  dentition,  but  that  their  causes  are  to  be  sought  for  in  a 
predisposition  dependent  upon  the  age  of  the  infant,  and  the  peculiar  physiolo- 
gical condition  then  present — the  normal  predominence  of  activity  in  certain  of 
the  vital  functions,  while  their  production  is  directly  traceable  to  errors  in  feed- 
ing, deficient  personal  cleanliness,  impure  air,  defective  ventilation,  want  of  due 
exercise,  accidental  injuries,  and  the  like.  It  is  not  the  less  true,  however,  that 
the  morbid  phenomena  referred  to  are  very  generally  aggravated  by  dentition, 
while  the  latter,  as  already  remarked,  may  become  the  sole  exciting  cause  when- 
ever there  exists  an  abnormal  predisposition  to  morbid  action  in  one  or  other 
of  the  organs.  Dentition  will  also  be  attended  with  more  or  less  suffering  in  those 
instances  in  which  the  evolution  of  several  of  the  teeth  takes  place  simultaneously 
or  in  quick  succession,  or  where  there  is  a  deficient  development  of  the  jaws.  ' 

The  foregoing  positions  will,  we  are  confident,  be  found  fully  established  by 
the  experience  of  every  observing  physician.  It  is  very  certain  that  in  the  lec- 
tures before  us  nothing  has  been  adduced  which  in  the  slightest  degree  tends  to 
show  their  inaccuracy.  The  entire  chain  of  reasoning  by  which  Dr.  Jacobi  has 
endeavoured  to  show  that  in  our  estimate  of  the  etiology  of  the  diseases  of  infancy 
the  action  of  dentition  must  be  entirely  omitted  is  particularly  specious  and  in- 
conclusive. We  do  not,  however,  wish  to  be  understood  as  including  in  one 
general  condemnation  the  lectures  before  us.  On  the  contrary  they  are  replete 
with  important  truths,  well  set  forth,  and  adapted  to  remove  many  errors  into 
which  physicians  have  fallen  in  respect  to  the  maladies  of  infant  life  and  their 
relationship  to  dentition.  The  study  of  these  lectures  will  be  found  profitable 
to  every  one  engaged  in  the  practice  of  medicine.  If  their  publication  should 
do  no  other  good  than  to  put  a  stop  to  the  unnecessary,  often  injurious,  cutting 
and  hacking  of  the  gums  of  the  infant,  which  is  every  day  performed,  and  often 
repeated  several  times,  at  short  intervals,  in  the  same  subject,  under  the  pretence 
of  favouring  by  it  a  more  easy  and  rapid  protrusion  of  the  teeth,  and  in  this 
manner  guarding  against  the  occurrence  of  disease,  or  facilitating  the  removal 
of  this  when  it  has  already  made  its  appearance,  they  will  have  answered  an  ex- 
cellent purpose. 

"  I  see  few  indications,"  Dr.  Jacobi  remarks,  "  for  the  lancet  during  the  period 
of  dentition.  You  may  cut  where  the  gums  are  an  impediment  to  the  protrusion 
of  a  tooth,  or  where  the  gums  themselves  are  the  seat  of  a  disease  giving  rise- to 
general  symptoms,  especially  of  the  nervous  system.  Thus,  inflammation  of  the 
gums  justifies  an  incision  for  the  sake  of  relieving  the  tension  of  the  tissue. 
Kven  mild  cases  in  very  irritable  children  may  be  treated  in  the  same  way.  But 
the  incision,  especially  when  repeated,  may  itself  become  a  cause  of  irritation, 
sometimes  evidenced  by  the  fact  that  during  the  prevalence  of  follicular  or  other 
form  of  stomatitis  the  gums  will  be  found  covered  with  superficial  ulcerations. 
I  need  not  add,  that  while  exudative  processes,  such  as  diphtheria,  are  active 
in  the  system,  every  wound  inflicted  will  give  rise  to  new  diphtheritic  deposits. 
I,  then,  scarify  the  gums  in  cases  of  intense  local  hypera3mia  and  inflammation 
—where  the  loss  of  a  few  drops  of  blood,  which  can  have  no  effect  on  either  the 


1863.] 


J  A  cob  i,  Dentition  and  its  Derangements. 


165 


healthy  or  diseased  general  system,  is  decidedly  advantageous.  I  should  scarify 
in  cases  of  convulsions  in  tender,  irritable  patients,  in  whom  I  found  the  gums 
swollen,  and  wnere  a  correct  diagnosis  could  be  made  instantaneously — especi- 
ally in  such  as  had  been  once  relieved  by  the  same  operation  :  for  I  must  con- 
fess that  once  or  "ftvice  in  my  life,  not  fttener,  I  have  observed  the  instant  ter- 
mination of  an  attack  of  convulsions  after  I  had  lanced  the  gums.  But  always 
be  sure  that  the  tooth  is  near  the  surface.  I  know  that  new  cicatrices  will  easily 
tear,  but  old  ones  will  not,  and  I  have  seen  trouble  to  arise  from  teeth  which 
were  cut  down  upon  weeks  or  months  before  they  were  ready  to  pierce  the  gums  ; 
a  practice  always  annoying  to  the  child,  and  useless  or  even  dangerous,  and  cer- 
tainly not  indicative  of  much  power  of  diagnosis  or  therapeutical  knowledge  in 
the  doctor.  It  is  not  uncommon,  even,  to  find  a  retardation  of  the  protrusion 
of  a  tooth  when  you  expected  it  daily  to  appear.  A  child  becomes  sick,  with 
symptoms  of  fever  and  others  of  a  local  character  ;  you  lance  the  gums,  and  not 
only  expect  the  appearance  of  the  tooth,  but  a  termination,  also,  of  the  untoward 
symptoms.  Nothing  of  the  kind  occurs.  On  the  contrary,  the  child  gets  thinner 
and  sicker,  and  yet  no  tooth.  Where  the  system  is  intensely  suffering,  where 
emaciation  takes  place  and  nutrition  is  interfered  with,  it  is  but  natural  that  the 
growth  of  a  tooth  should  also  stop.  In  such  cases  you  may  safely  predict  that 
no  tooth  will  appear  before  the  child  gets  well,  or,  at  least,  better.  During 
convalescence  the  tooth  appears.  It  made  its  appearance  after  the  organism 
had  been  sufficiently  restored  to  allow  of  phosphate  of  lime  being  spared  for  the 
building  of  teeth,  but  the  mother  says,  that,  because  the  child  was  well  when  the 
tooth  came,  therefore,  the  child  suffered  from  its  tooth." 

"  In  one  of  my  first  lectures,  I  spoke  of  the  direct  injury  done  to  the  tooth  by 
incisions.  The  consistency  of  the  tooth  is  the  less  the  younger  the  child  ;  and 
that  harm  may  be  done  to  a  tooth  by  the  action  of  a  hard,  sharp  instrument 
cannot  be  denied.  If  you  expect  to  effect  anything  by  an  incision,  you  must  be 
sure  to  divide  the  gum  down  to  the  tooth.  But  you  can  scarcely  avoid  injuring 
the  tooth  in  cutting  down  upon  it.  If  this  danger  exists,  and  it  certainly  does, 
it  is  the  more  to  be  feared  from  those  often  repeated  scarifications  recommended 
by  Marshall  Hall,  and  others.  Thus,  while  your  incisions  are  of  no  use  in  the 
present,  they  are  positively  injurious  in  the  future." 

There  is  much  sound  practical  sense  in  the  foregoing  remarks — all  may  profit 
by  them. 

We  agree  very  fully  with  the  remarks  made  by  Dr.  Jacobi  in  reference  to  the 
leading  diseases  of  the  mouth,  their  etiology  and  pathology,  and  their  relation  to 
dentition,  which  in  the  great  majority  of  cases  is  merely  that  of  coincidence. 

The  author's  account  of  retro-  or  latero-pharyngeal  abscess  is  particularly 
interesting.  He  describes  it  as  one  of  the  sequelae  of  ordinary  pharyngitis.  It 
is  attended  with  rather  severe  pain,  and  considerable  exudation.  A  semi-spheri- 
cal, livid,  brilliant  tumour  being  seen  or  felt  on  the  posterior  or  lateral  wall  of 
the  pharynx.  Respiration  and  deglutition  are  difficult — there  is  cough,  with 
thickness  or  hoarseness  of  voice — emaciation — high  fever,  sometimes  attended 
with  convulsions,  which  may  also  be  induced  by  the  swelling  of  the  tissues  of 
the  neck,  and  the  consequent  compression  of  the  venous  trunks.  The  abscess 
generally  forms  pretty  slowly,  and  in  this  may  sometimes  be  distinguished  from 
acute  tonsillitis  or  stenotic  disease  of  the  larynx.  If  the  contents  of  the  abscess 
be  evacuated  by  an  incision  or  spontaneous  rupture,  the  danger  of  suffocation  is 
removed,  and  soon  all  severe  symptoms  will  disappear.  The  spontaneous  evacu- 
ation of  the  pus  is  not  to  be  depended  on  ;  in  the  majority  of  cases  an  incision 
will  be  necessary.  There  is  imminent  danger  of  suffocation  from  the  mere  size 
of  the  abscess,  and  the  attendant  swelling  of  the  surrounding  tissue,  especially 
the  velum  palati  and  posterior  nares.  Danger  may  also  arise  from  the  extension 
of  disease  to  the  larynx,  increasing  thus  the  liability  to  suffocation,  or  from 
the  occurrence  of  grave  consecutive  diseases,  or  the  Eustachian  tube  may  be- 
come affected,  and  impairment  of  hearing  or  total  deafness  ensue.  The  clanger 
from  the  impairment  of  deglutition  is  less  imminent,  want  of  food  can  be  en- 
dured longer  than  the  want  of  air,  while  food  can  be  introduced  in  case  of  neces- 
sity by  other  avenues  than  the  mouth  and  oesophagus. 

Retro-pharyngeal  abscess  is  seated  in  the  cellular  tissue  interposed  between 


166 


Bibliographical  Notices. 


[Jan. 


the  pharynx  and  vertebral  column.  The  lecturer  divides  these  abscesses  into 
three  classes:  1st.  The  idiopathic,  resulting  from  simple  inflammation  of  the 
mouth,  pharynx,  and  surrounding  tissues,  or  a  metastatic  process  connected  with 
an  acute  exanthem,  typhoid  fever,  or  l^aemia.  The  majority  of  cases  occur 
before  or  during  the  first  dentition — thw  period  of  infancy  being  that  in  which 
there  is  the  greatest  tendency  to  catarrhal  affections  of  the  throat.  The 
prognosis  is  generally  favourable  if  incision  of  the  abscess  be  not  neglected. 
Metastatic  abscesses,  however,  are  of  a  more  dangerous  character,  being  merely 
the  symptoms  of  a  more  or  less  grave  affection  of  the  general  system.  Idiopathic 
abscesses  require  in  their  first  stage  a  rational  antiphlogistic  local  treatment. 
Cold  applied  both  internally  and  externally ;  the  first  by  the  slowly  swallowing 
of  ice,  or  gargling  with  iced  water,  with  or  without  the  addition  of  alum  ;  the 
local  application  of  nitrate  of  silver,  or  alum,  scarifications  of  the  larynx,  leeches. 
When  suppuration  cannot  be  prevented,  warm  poultices  are  to  be  resorted  to, 
excepting  when  there  is  danger  from  cerebral  congestion  ;  here  warm  emollient 
gargles  are  to  be  preferred.  Internal  treatment  is  available  only  so  far  as  it  is 
adapted  to  diminish  fever  or  other  dangerous  symptoms.  When  the  danger  of 
suffocation  is  imminent,  the  abscess  should  be  opened  at  once  by  incision  and 
its  cavity  washed  out  by  gargling  or  syringing  with  water,  but  in' the  case  of 
what  are  termed  metastatic  abscesses,  to  promote  their  healing  the  applica- 
tion of  stimulants  and  astringents  is  required — such  as  chlorate  of  lime,  alum, 
nitrate  of  silver,  tannic  acid,  while  the  proper  internal  treatment  must  be  deter- 
mined by  the  nature  of  the  general  affection.  Bark,  and  the  mineral  acids  will 
generally  be  indicated. 

The  second  form  of  retro-pharyngeal  abscess  includes  such  as  result  from  the 
suppuration  (usually  in  scrofulous  subjects)  of  inflamed  lymphatic  glands  and  the 
surrounding  tissues.  They  are  rarely  met  with  previously  to  the  completion  of 
the  period  of  the  first  dentition.  The  prognosis  is  in  general  sufficiently  favour- 
able, provided  the  original  suppuration  is  not  excessive  and  the  general  morbid 
condition  of  the  system  is  moderate  in  extent.  The  local  treatment  will  be  much 
the  same  as  in  the  case  of  idiopathic  abscess.  The  primary  attention  is  to  be 
paid,  however,  to  the  original  glandular  abscess,  the  pus  of  which  may  often  be 
evacuated  by  an  incision  from  without,  with  the  effect,  also,  of  relieving  the  con- 
secutive pharyngeal  and  laryngeal  injection.  The  gravity  of  the  general  dyscratic 
affection  calls  for  serious  consideration.  The  employment  of  the  iodides  of 
potassium  and  of  iron,  cod-liver  oil,  pure  air,  sufficient  exercise,  attention  to  the 
skin,  and  a  generous  diet,  will  be  strongly  indicated. 

A  third  form  of  retro-pharyngeal  abscess  is  dependent  upon  suppuration 
seated  in  the  cervical  vertebrae  or  their  ligaments,  occurring  at  a  period  of  life 
earlier  than  the  preceding  form.  The  prognosis  in  these  cases  is  very  unfa- 
vourable. The  opening  of  the  abscess  should  be  deferred  as  long  as  possible ; 
it  can  only  afford  temporary  relief  to  the  difficulty  of  respiration  and  degluti- 
tion. The  treatment  must  be  by  quietude,  posture,  cold  applications,  leeches, 
mercury  and  wine,  nitrate  of  potassa,  tartar  emetic,  iodide  of  potassium,  and 
preparations  of  iron,  according  to  the  indications  presented  in  each  case.  Little 
dependence,  however,  is  to  be  placed  in  any  course  of  treatment,  as  the  disease 
will  in  nearly  every  case  terminate  fatally,  either  very  suddenly  or  after  the 
gradual  occurrence  of  great  exhaustion  attended  with  hectic  fever.  Br.  Jacobi 
knew  of  one  case,  occurring  in  a  young  man,  to  terminate  suddenly  while  the 
patient  was  in  the  act  of  turning  his  head  on  the  pillow.  Examination  after 
death  showed  the  ligaments  of  the  spinal  column  at  its  upper  portion  to  be  de- 
stroyed to  within  a  few  shreds,  which  were  torn  by  the  last  movement  of  the 
patient,  allowing  the  process  of  the  vertebra  dentata  to  enter  the  foramen  mag- 
num and  destroy  the  tissue  of  the  medulla  oblongata. 

There  is  scarcely  a  lecture  in  the  volume  before  us  which  does  not  present 
matter  worthy  of  especial  notice.  The  entire  validity  of  the  views  presented 
by  the  author  in  respect  to  the  nature,  seat,  and  causation  of  the  several  infantile 
diseases  of  which  he  treats  we  may  not,  it  is  true,  be  able  always  to  acknowledge; 
the  facts  and  arguments,  nevertheless,  by  which  he  has  endeavoured  to  enforce 
and  illustrate  them  are  always  deserving  of  a  candid  examination,  and  in  many 
instances  they  are,  it  must  be  admitted,  particularly  suggestive.    We  should  be 


1863.] 


Jacobi,  Dentition  and  its  Derangements. 


161 


pleased,  could  we  spare  the  space,  to  present  an  analysis  of  the  greater  portion 
of  those  of  the  lectures  which  are  of  a  strictly  pathological  character. 

Dr.  Jacobi's  exposition  of  the  nature  and  causation  of  infantile  convulsions 
are  particularly  interesting;  we  shall  confine  our  notice,  however,  to  his  account 
of  laryngismus  stridulus  or  the  crowing  inspiration  of  children. 

The  first  stage  of  this  affection  he  refers  to  the  sudden  occurrence  of  com- 
plete apncea.  Kespiration  is  suddenly  and  completely  arrested  for  some  seconds  ; 
the  face  becomes  bloodless  and  pale,  and,  finally,  cyanotic,  if  the  paroxysm  is 
of  any  duration.  The  skin  is  cool,  and  the  action  of  the  heart  scarcely  percept- 
ible, the  entire  muscular  system  being,  according  to  Dr.  Jacobi,  in  a  state  of 
paralysis.  In  the  second  stage  he  supposes  that  reaction  commences.  The 
recurrent  branch  of  the  pneumogastric  nerve  excites  the  function  of  the  muscles 
of  the  glottis,  and  the  spinal  nerves  that  of  the  other  respiratory  muscles,  so 
as  to  cause  a  forced,  deep  "crowing"  inspiration.  During  the  third  stage  re- 
action becomes  complete.  By  short  convulsive  expirations  the  functions  of  the 
respiratory  organs  are  restored  to  their  normal  condition.  Attacks  of  great 
intensity  and  long  continuance  are  commonly  attended  with  contractions  of  the 
hands,  and  even  general  tonic  convulsions  of  the  trunk  and  lower  extremities. 
In  some  cases  general  eclampsia  has  been  known  to  accompany  the  attack,  but 
to  return  without  any  recurrence  of  the  latter;  or  the  laryngismus  may  recur 
without  the  eclampsia.  Involuntary  evacuations,  caused,  as  Dr.  Jacobi  sup- 
poses, by  paralysis  of  the  sphincter  muscles,  have  been  observed  during  the 
attack.  The  paroxysms  of  laryngismus  recur  at  longer  or  shorter  intervals ; 
several  may  take  place  in  a  single  day.  The  disease  is  seldom  fatal.  It  may 
last  for  months  and  even  years.  When  death  ensues  during  the  attack  it  is  in 
the  first  stage. 

The  mildness  or  severity  of  the  attacks  of  laryngismus  depend  as  well  upon 
the  constitution  of  the  patient  as  upon  the  nature  of  the  occasional  causes. 

Dr.  Jacobi  believes  that  the  symptoms  of  the  first  stage  of  this  affection  can 
only  be  explained  by  supposing  a  functional  disturbance  of  the  nervous  system — 
paralysis,  perhaps,  of  the  medulla  oblongata,  or  of  the  nervous  centres  gene- 
rally. Paralysis  of  the  muscles  of  the  glottis  alone,  he  remarks,  would  not  be 
sufficient  to  produce  all  the  symptoms  of  the  first  stage  of  laryngismus ;  these 
do  not  occur  upon  the  division  of  a  recurrent  nerve.  The  division  of  both  nerves 
gives  rise  pretty  rapidly  to  suffocation,  but  not  suddenly,  while  the  lungs  and 
brain  become  engorged,  whereas  the  morbid  anatomy  of  laryngitis  shows  entire 
absence  of  hyperemia  of  the  brain,  and  little  or  no  blood  in  the  heart  and  cuta- 
neous veins.  Death  in  laryngismus,  according  to  Dr.  J.,  ensues  precisely  in  the 
same  manner  as  it  does  in  animals  in  whom  the  medulla  oblongata  has  been 
divided. 

The  crowing  inspiration  is  very  correctly  described  as  a  symptom  which  does 
not  exclusively  appertain  to  laryngismus  stridulus ;  it  is  met  with  also  in  laryn- 
geal catarrh,  in  which  disease  the  muscles  of  the  vocal  cords  are  spasmodically 
affected. 

We  agree  fully  with  our  author  in  the  remark  that  the  cause  of  laryngismus 
is  to  be  sought  for  in  some  affection  of  the  nervous  centres.  It  is  very  evident 
that  no  disease  of  any  portion  of  the  respiratory  organs  is  attended  by  symp- 
toms similar  to  those  which  characterize  laryngismus,  and  in  the  examination  of 
the  bodies  of  those  who  have  fallen  victims  to  it  no  lesions  of  the  heart  and  lungs 
sufficient  to  explain  its  production  have  been  detected.  Goelis  long  ago  noticed 
the  occurrence  of  a  mild  form  of  laryngismus  in  connection  with  chronic  hydro- 
cephalus. Keitel  found,  besides  a  hypertrophied  and  degenerated  thymus  gland, 
softness  of  the  skull,  with  large  fontanels  and  sutures,  a  softened  and  hyperaemic 
condition  of  the  cerebral  tissues,  with  softness  of  the  medulla  oblongata  and 
congestion  of  its  membranes,  and  a  tablespoonful  of  clear  serum  at  the  upper 
portion  of  the  vertebral  canal.  In  one  case  Marshall  Hall  found  abnormal 
hardness  of  the  medulla  oblongata.  Evans  relates  that,  in  a  child  with  conge- 
nital spina  bifida,  an  attack  of  laryngismus  was  produced  whenever  the  fluid  in 
the  sac  was  pressed  into  the  vertebral  canal.  Caspari  found  the  substance  of 
the  spinal  cord  solid  and  white,  with  considerable  injection  of  its  dura  mater. 
The  sinuses  of  the  brain  were  enormously  distended  with  thin  black-coloured 


163 


Bibliographical  Notices. 


[Jan. 


blood,  and  the  substance  of  both  cerebral  hemispheres  and  of  the  cerebellum 
very  soft.  The  phrenic  nerves  were  unusually  hard,  while  the  pneumogastric 
nerve  u  appeared  more  similar  to  the  brain."  Facts  of  this  kind  could  be  greatly 
multiplied,  showing  the  dependence,  in  a  large  number  of  instances,  of  laryn- 
gismus upon  lesions  of  the  nervous  centres.  It  is  to  be  recollected,  however, 
that  diseased  conditions  of  the  brain  and  medulla  oblongata,  precisely  similar  to 
those  met  with  in  patients  who  have  perished  from  an  attack  of  laryngismus,  fre- 
quently occur  without  the  occurrence  of  any  symptom,  even  the  slightest,  of  the 
latter.  We  believe  that,  in  every  instance,  laryngismus  is  strictly  a  nervous  affec- 
tion, dependent,  in  very  many  cases,  on  disease  of  the  nervous  centres,  but  more 
frequently  upon  reflex  irritations  having  their  origin  in  some  morbid  condition 
of  remote  organs.  We  cannot  admit,  however,  that  the  condition  of  the  nervous 
centres  giving  rise  to  laryngismus  is,  as  Dr.  Jacobi  supposes,  that  of  paralysis ; 
we  can  find  nothing  in  the  symptoms,  course,  and  termination  of  the  disease 
that  would  seem  to  indicate  the  presence  of  paralysis  of  certain  of  the  respira- 
tory muscles,  but  rather  in  every  case  their  spastic  contraction. 

There  is  a  morbid  condition  met  with  during  infancy  which,  according  to  our 
author,  is  a  very  fruitful  cause  of  laryngismus ;  that  is,  a  rachital  softening  of 
the  parietal  and  occipital  bones,  but  especially  of  the  latter,  to  which  the  term 
craniotabes  has  been  applied.  Kopp,  Caspari,  Pagenstecher,  Hirsch,  Keitel, 
Hachman,  Gunther,  Landsberg,  Hauff,  Staub,  and  other  of  the  old  writers  col- 
lected by  Elsaesser  in  his  work  on  the  "  Soft  Occiput,"  without  recognizing  the 
intimate  connection  of  the  two  morbid  conditions,  have  described  cases  of  laryn- 
gismus in  which  softening  of  the  parietal  and  occipital  bones  constituted  one  of 
the  most  prominent  lesions.  It  is  very  certain,  however,  that  after  the  most 
careful  analysis  of  the  observations  on  record  in  respect  to  rachital  softening  of 
the  cranium,  that  laryngismus  will  occur  in  numerous  instances  where  there  does 
not  exist  a  trace  of  craniotabes.    Dr.  Jacobi  says  : — 

"  I  hardly  remember  a  case  of  my  own,  in  which  symptoms  of  general  rhachitis 
and  of  rhachidial  softening  of  the  cranium  were  absent  in  laryngismus ;  this 
much  is  certain,  that  the  majority  of  cases  of  laryngismus  or  crowing  inspiration, 
depend  on  craniotabes  and  general  rhachitis.  It  is  always  the  great  predis- 
posing cause,  and  thus,  the  last  and  proximate  causes  of  an  attack  of  our  dis- 
ease, as  we  find  them  enumerated  in  the  text-books— such  as  fright,  anger,  cough, 
protrusion  of  a  tooth,  etc.,  are  assigned  their  right  place  of  but  occasional  and 
temporary  importance.  By  the  defective  condition  of  the  cranium  the  brain  is 
more  liable  to  external  injuries  from  concussion  caused  by  quick  movements  of 
the  head,  or  an  improper  mode  of  carrying  on  the  arm,  violent  rocking,  etc. — 
from  lying  on  too  hard  a  pillow,  from  too  high  a  temperature  both  artificial  and 
solar,  and,  finally,  we  must  not  overlook  the  importance  of  such  alterations  as 
invariably  take  place,  in  rhachitis  and  craniotabes,  in  the  nutrition  of  the  system 
and  the  condition  of  the  brain.  At  all  events  you  will  hardly  ever  be  mistaken 
in  your  etiology,  when  on  meeting  with  a  case  of  laryngismus,  you  examine  for 
craniotabes.  Whenever  a  child  with  laryngismus  is  brought  to  me,  my  first 
attention  is  given  to  the  occiput  and  epiphyses,  as  my  first  prescription  is  almost 
invariably  the  regulation  of  the  diet  and  the  use  of  iron." 

Our  experience  in  respect  to  the  frequency  of  the  connection  between  laryn- 
gismus and  a  rachitic  condition  of  the  infantile  system,  with  softening  and 
wasting  of  the  cranial  bones,  differs  from  that  of  Dr.  Jacobi.  We  have  cer- 
tainly observed  laryngismus  to  occur  often  in  rickety  children,  but  more  fre- 
quently in  those  in  whom  no  trace  of  a  rachitic  taint  was  to  be  detected.  The 
infants  most  liable  to  it  are,  according  to  our  experience,  pale  and  anaemic, 
excitable  and  fretful,  who  awaken,  as  it  were,  in  a  fright  upon  the  slightest 
noises  made  in  their  vicinity,  and  who  are  wakeful,  restless,  and  unsatisfied 
unless  constantly  on  the  move. 

The  most  frequent  exciting  causes  we  should  say,  are  sudden  and  abrupt 
movements  of  the  child,  especially  any  undue  jolting  of  the  head  and  body,  im- 
proper food,  and  an  impure,  stagnant,  or  irritating  condition  of  atmosphere. 
Among  these  the  most  effective  in  the  production  of  laryngismus  are  the  im- 
proper quality  of  the  infant's  food,  and  its  exposure  to  malarious  influences. 

This  fact,  which  is  recognized  by  the  major  portion  of  the  more  recent 


1863.]      Annual  Meeting  of  the  British  Medical  Association.  169 


English  and  French  writers  on  the  disease,  it  is  important  to  keep  constantly  in 
mind,  inasmuch  as.  in  a  very  large  number  of  cases,  it  is  in  vain  to  attempt  the 
arrest  of  laryngitis  by  any  course  of  treatment  until  the  little  patient  is  put 
upon  a  proper  and  well  regulated  diet,  and  subjected  to  the  influence  of  a  free, 
pure  atmosphere  of  suitable  temperature.  This  alone  we  have  often  known  to 
suspend  the  paroxysms,  which  had  previously  been  of  frequent  occurrence. 

Although  laryngismus  is  a  disease  of  the  period  of  infant  life,  during  which 
the  process  of  teething  is  most  active,  we  have  no  reason  for  supposing  that  the 
latter  is  a  very  common  exciting  cause  of  it;  when,  however,  the  gum  over  the 
advancing  teeth  is  greatly  swollen,  hard  and  red,  the  mouth  is  hot,  "and  the  child 
evidently  suffers  pain  in  its  mouth,  a  careful  incision  of  the  gum  is  equally  ad- 
visable in  children  labouring  under  laryngismus  as  it  would  be  under  any  other 
circumstances. 

We  earnestly  commend  the  lectures  of  Dr.  Jacobi  to  the  favourable  considera- 
tion of  the  profession  at  large.  They  are  replete  with  instruction  in  relation  to 
many  important  points  connected  with  infantile  pathology  which  are  not  well 
understood  by  a  large  number  of  practitioners.  The  author  has  done  ample 
justice  to  his  subject  and  its  literature,  whether  the  lectures  are  viewed  simply 
as  presenting  an  exposition  of  the  physiology  of  dentition  and  its  derangements, 
or  as  a  general  review  of  the  nature,  seat,  and  causes  of  those  diseases  which 
are  usually  observed  during  the  period  of  dentition.  His  object  is  evidently  the 
attainment  of  correct  views  in  respect,  more  especially,  to  the  etiology  of  the 
maladies  just  referred  to,  and  although  he  may,  perchance,  have  ignored  to  too 
great  an  extent  the  influence  of  dention  in  their  production,  his  teachings  can- 
not fail  to  have  the  beneficial  effect  of  directing  the  medical  practitioner  to  a 
recognition  of  the  entire  want  of  foundation  for  the  common  opinion  so  long 
entertained  by  the  public  as  well  as  by  the  profession,  everywhere,  that  teething 
is  usually  a  painful  process,  and  one  of  the  most  usual  and  efficient  of  the  pre- 
disposing and  exciting  causes  of  the  maladies  of  infancy.  An  opinion  not 
simply  unsupported  by  facts,  but  one  adapted  to  cause,  on  the  one  hand,  the 
true  etiology  of  many  important  diseases  to  be  overlooked ;  and  on  the  other 
hand,  to  lead  to  the  adoption  of  a  practice  always  useless  and  often  mischievous. 

D.  F.  C. 


Art.  XXY. — Addresses  delivered  by  Dr.  Burrows.  Dr.  Walshe,  Mr.  Paget, 
and  Dr.  Sharpey,  at  the  Thirtieth  Annual  Meeting  of  the  British  Medical 
Association,  held  at  the  Royal  College  of  Physicians,  London,  in  1862. 
London,  1862.    12mo.  pp.  98. 

The  British  Medical  Association,  it  is  well  known,  was  formed  several  years 
ago  by  incorporating  with  the  Provincial  Medical  Association  the  members  of 
the  medical  profession  in  the  metropolis.  Its  recent  meeting,  the  first  held  in 
London,  was  remarkable  for  the  large  number  of  gentlemen  who  took  part  in 
its  business,  and  for  the  character  of  the  Addresses  with  which  it  was  opened. 
These,  which  have  been  thought  worthy  of  preservation  in  a  separate  form,  are 
contained  in  the  pamphlet  before  us. 

The  first  of  them,  delivered  by  the  President,  Dr.  Burrows,  sets  forth  the 
grounds  which  have  been  made  familiar  to  us  in  our  own  State  Medical  Societies 
and  in  the  American  Medical  Association,  and  upon  which  the  union  of  physi- 
cians for  the  diffusion  of  medical  knowledge,  and  the  maintenance  of  the  honour 
and  interests  of  the  medical  profession,  are  to  be  promoted  and  secured.  In 
England,  as  at  home,  it  has  been  found  that  the  medical  profession  has  profited 
by  the  existence  of  the  Association  in  the  development  of  new  ardour  in  the 
pursuit  of  scientific  discovery,  in  the  improvement  of  practical  medicine  and 
surgery,  and  in  the  elevation  of  the  professional  status,  while  its  influence  upon 
the  national  legislature  in  favour  of  improved  laws  for  the  organization  and 
government  of  the  medical  profession  has  been  very  salutary.  Dr.  Burrows 
sketches  very  appropriately  the  tendency  of  modern  civilization  to  nationalize 


no 


Bibliographical  Notices. 


[Jan. 


all  tho  agencies  for  intellectual,  moral,  and  national  advancement,  by  substituting 
for  close  corporations  with  exclusive  privileges,  institutions  of  a  larger  scope  and 
a  more  catholic  spirit.  Fortunately,  in  some  respects  at  least,  this  country  was 
never  afflicted  by  similar  drags  upon  the  advancement  of  the  learned  professions ; 
while  in  France  they  have  not  existed  since  the  national  spirit  of  her  people 
was  fully  aroused  at  the  formation  of  her  first  republic.  It  is  a  gratifying  spec- 
tacle to  see  the  ancient  institutions  of  science  and  learning  in  England  yielding 
more  and  more  to  the  necessity  of  opening  the  avenues  of  knowledge,  and  con- 
fessing that  the  gifts  of  genius  and  the  fruits  of  scientific  inquiry  are  to  be  sought 
quite  as  often  beyond  the  limits  of  social  and  chartered  orthodoxy  as  within 
them.  It  appears,  however,  that  in  England,  as  in  this  country,  institutions  are 
to  be  found  which  protest  by  their  action  against  the  more  generous  spirit  which 
incites  the  profession,  and  which  cling  to  the  ancient  paths  with  a  tenacity  which 
renders  the  purity  of  their  motives  suspicious.  The  orator  admits,  as  has  so 
often  been  confessed  here,  that  to  attempt  the  removal  of  such  obstructions  by 
legal  methods  would  be  injudicious ;  but  he  assures  his  hearers,  in  the  same 
spirit  that  has  animated  American  medical  reformers,  that  "  if  the  British  Medi- 
cal Association  can,  by  its  numbers  and  proceedings,  carry  public  opinion  along 
with  it,  then  it  has  an  intrinsic  power,  equal  to  any  that  could  be  granted  by  the 
legislature,  and  this  moral  power  may  be  applied  to  the  production  of  the  most 
beneficial  results." 

The  Address  in  medicine,  by  Dr.  Walshe,  is  in  every  respect  worthy  of  its 
author,  and  is  beyond  comparison  the  gem  of  the  collection,  whether  in  style, 
thought,  or  argument.  Its  object  is  stated  to  be  an  inquiry  into  the  ultimate 
causes  and  the  mechanism  of  the  recent  progress  in  medicine.  The  first  of  these 
causes,  says  Dr.  Walshe,  is  an  improved  method  in  observing  and  recording 
medical  facts.  He  shows  how  transitory  and  insufficient  have  been  all  conclu- 
sions in  medicine  which  have  had  any  less  substantial  basis,  and  defends  from 
the  sneers  of  superficial  men  that  slow,  toilsome,  and  ungrateful  labour  of  col- 
lecting the  materials  upon  which  alone  doctrines  can  securely  rest.  He  contrasts 
the  deductive  with  the  inductive  method,  and  shows  that  while  the  former  is  ap- 
propriate in  certain  departments  of  philosophy,  it  is  misplaced  in  medicine,  and 
has  never  given  birth  to  any  but  a  short-lived  offspring,  as  most  precocious 
children  are  who  are  the  idols  of  their  parents  and  the  pests  of  all  the  world 
besides.  "  History,"  he  remarks,  "  not  only  teaches  us  the  absolute  failure 
of  all  such  systems,  but  shows  that,  so  long  as  the  deductive  method  prevailed, 
all  progress  must,  if  not  solely,  at  least  essentially,  consist  in  the  destruction  of 
something  gone  before.  The  energies  of  genius  must  be  wasted  in  negativing 
the  errors  of  the  past."  He  might  have  enforced  the  doctrine  of  his  theme  by 
those  striking  lines  of  the  philosopher-poet : — 

"  Grau  Freund  ist  alle  Theorie, 
Doch  griiu  des  Lebeu's  goldner  Baum." 

On  the  subject  of  "  pathological  laws,"  Dr.  Walshe  has  also  much  sound  doc- 
trine. He  shows  that  such  laws  are  not  to  be  claimed  as  absolute,  but  only  as 
formulae  expressing  the  actual  state  of  positive  knowledge,  the  results  arrived  at 
by  the  numerical  analysis  of  accurately  observed  facts;  results  which  maybe 
more  or  less  modified  by  the  next  fact  which  is  added  to  the  series,  but  which 
are,  nevertheless,  infinitely  nearer  the  truth,  than  any  which  a  different  process 
can  evolve.  The  author  proceeds  to  show  how  completely  the  results  obtained 
by  this  method  have  achieved  the  empire  of  the  medical  world,  and  reduced  to 
mere  nothingness  the  theoretical  speculations  of  genius  and  the  authority  of 
mere  names,  when  the  one  soars  from  clouds  instead  of  solid  earth,  and  the  other 
usurps  a  control  which  is  legitimate  in  nature  alone.  "  No  amount  of  past 
achievement  in  an  investigator,"  he  remarks,  "no  perfection  of  intellectual  bril- 
liancy in  a  teacher,  no  universality  of  belief  in  any  particular  man's  endowments, 
no  humility  of  'hero  worship,'  will  save  any  opinion,  any  creed,  any  statement 
of  alleged  facts  from  the  critical  revisal  of  the  humblest  and  the  newest  worker 
in  the  field,  or  protect  one  or  the  other  from  inevitable  destruction  if  that  revisal 
detect  a  flaw." 

Such  a  course  of  argument  and  such  illustrations  as  Dr.  Walshe  uses  to  en- 


1863.]      Annual  Meeting  of  the  British  Medical  Association.  171 


force  the  leading  principle  of  his  discourse,  we  employed  some  twelve  years  ago 
in  an  essay  on  Medical  Truth.1  They  had  the  honour  of  being  pooh-poohed,  at 
the  time,  by  the  leading  British  Medical  Keview;  but  as  they  had  even  then  their 
advocates,  and  evidences  of  their  soundness  abounded  on  every  side,  we  were 
content  to  await  the  verdict  in  their  favour  which  time  never  fails  to  award  to 
truth.  We  then  jcited  the  improvements  in  thoracic  pathology  due  to  Dr. 
Walshe  as  examples  of  the  fruits  which  the  numerical  method  of  investigation 
had  produced,  and  we  are  now  doubly  gratified  in  reading  his  own  luminous 
and  convincing  exposition  of  the  method  itself.  Its  influence  upon  English 
and  American  medicine  cannot  be  small  when  directed  by  so  eminent  a  teacher; 
for  while  even  truths  divine  are  seldom  heeded  unless  uttered  by  a  voice 
potential,  the  dicta  of  authority  find  complacent  listeners,  and  obtain  a  prompt 
<$bnformity.  Even  now  there  are  minds  which  chafe  under  the  constraint 
of  a  method  of  investigation,  which,  as  Bacon  said  of  his  own,  "levels  men's 
wits  and  leaves  little  to  their  superiority,"  and  who,  under  the  inspiration  of  an 
impetuous  genius,  have  struck  out  theories  which  captivate  the  imagination 
and  dazzle  the  calm  and  steady  eye  of  reason  herself.  But  these  are  only 
sparks  and  flashes  which  the  ponderous  chariot-wheels  of  truth  strike  out  as 
she  rides  onward  conquering  and  to  conquer.  They  are  only  noisy  bursts  of 
vapour  which  admonish  us  of  her  progress,  or,  perchance,  relieve  the  super- 
abundant pressure  which,  but  for  them,  might  become  dangerous  to  science 
itself. 

In  what  Br.  Walshe  says  to  indicate  the  true  position  of  medicine  among  the 
sciences,  we  have,  also,  the  satisfaction  of  knowing  that  we  anticipated  several 
of  his  arguments  and  illustrations,  and  set  the  same  limits  which  he  assigns  to 
certainty  in  medicine,  viz.,  that  its  truths  apply  to  classes  of  facts  alone,  and  not 
to  individual  instances.  Hence,  prognosis  has  ever  been  the  most  difficult  part 
ofsmedicine,  the  despair  of  the  conscientious  physician,  and  the  quack's  most 
fertile  field ;  for  the  one  knows  that  to  foretell  with  certainty  is  impossible,  and 
the  other  that  a  lucky  guess  will  favour  his  fortune  a  thousand  times  more  than 
a  false  prediction  can  injure  it.  But  Br.  W.  is  not  content  with  an  affirmative 
vindication  of  the  certainty  of  medicine  ;  he  not  only  rebukes  the  sneer  which 
the  members  of  other  professions  are  apt  to  affect,  or  utter  in  ignorant  sincerity, 
but  he  shows  that  the  uncertainties  in  doctrine  and  practice  which  afflict  medi- 
cine are  neither  greater  nor  more  numerous  than  belong  to  every  other  depart- 
ment of  human  knowledge.  He  stigmatizes  as  it  deserves  the  fact  that  a  statis- 
tical investigation  into  the  health  of  the  British  army,  was  intrusted  to  a  captain 
in  the  service  instead  of  a  medical  man.  They  manage  these  things  better  in 
France  ;  and  even  among  us,  outer  barbarians  as  our  cousins  across  the  water 
at  present  consider  us,  such  an  insult  to  the  medical  profession  would  have  been 
impossible.  He  characterizes  with  equal  plainness  Ifhe  attempt  on  the  part  of 
certain  legal  members  of  the  legislature  to  exclude  skilled  medical  opinion  in 
cases  of  lunacy,  for  the  reason  that  "the  contradictions  of  medical  experts  inter 
se  are  so  constant  and  so  flagrant,  that  jurymen  are  likely  rather  to  be  led  astray 
by  the  conflict  of  their  opinions,  than  guided  by  the  clearness  of  their  technical 
knowledge."  That  this  is  a  difficulty  is  not  sought  to  be  denied :  "  But  the  onus 
probandi,  that  this  difficulty  makes  the  chances  of  the  jurymen  failing  to  reach 
the  right  conclusion  greater  than  it  would  be  without  such  conflict  of  opinion, 
rests  with  those  who  oppose  skilled  testimony."  And  the  critics  of  medical 
experts  are  reminded  that  just  as  great  a  conflict  of  testimony  as  to  matters  of 
fact  of  the  most  ordinary  kind  is  daily  to  be  observed,  in  witnesses  whose  intel- 
ligence and  probity  are  irreproachable.  "  If  the  bar  were  logical,"  it  is  added, 
"  they  should  then  plead  that  witnesses  as  to  matters  of  fact  might  henceforth 
be  silenced,"  and  that  skilled  opinion  of  every  kind  should  be  excluded  from 
court,  because  engineers,  and  architects,  and  surveyors,  and  all  other  persons 
whatsoever,  when  summoned  as  experts,  are  quite  as  discordant  in  their  opinions 
as  physicians.  But  most  of  all  is  this  discordance  to  be  seen  among  lawyers 
themselves.  The  very  business  of  their  lives  is  to  assert  what  others  contradict, 
and  to  deny  what  others  affirm.    If  it  is  said  that  they  do  so  perfunctorily,  and 


1  Elements  of  General  Pathology,  &c,  Phila.,  1848. 


Bibliographical  Notices. 


[Jan. 


not  as  individuals,  what  must  be  thought  of  the  notorious  dissidence  of  opinions 
in  judges  upon  the  bench,  whose  very  office  is  created  to  secure,  if  possible,  the 
agreement  of  the  weigh  test  authorities  ?  A  striking  example  is  mentioned  of 
this  antagonism  in  the  highest  court  of  England,  where,  upon  an  important  point 
of  law,  brought  there  by  appeal  from  below,  the  thirteen  judges  differed  in  their 
decision  as  much  as  it  was  possible ;  six  were  in  favour  of  and  six  against  the 
defendant,  and  the  case  was  only  decided  by  the  casting  vote  of  the  presiding 
judge.  "  And  these  are  the  men,"  exclaims  Dr.  Walshe,  "  who  would  silence 
medical  opinion  in  courts  of  justice,  on  the  plea  that  it  is  not  consistent !" 

He  further  contrasts  the  amount  of  knowledge  required  by  physicians  and 
lawyers  ;  the  latter  dealing,  in  the  main,  with  what  they  themselves  manufacture, 
the  former  with  the  mysteries  of  nature;  the  one  having  to  expound  the  works 
of  man,  the  other  to  interpret  the  works  of  God.  But  because  physicians,  whe% 
called  into  court,  often  disagree  in  the  interpretation  of  facts,  lawyers  would 
exclude  them  entirely.  The  Lord  Chancellor-  himself  denounces  the  idea  that 
any  one  should  "  have  studied  medicine  in  order  to  determine  whether  a  man 
was  or  was  not  a  lunatic,  as  an  absurdity  /"  Again,  we  must  say,  "  they  manage 
these  things  better  in  France,"  and  we  might  add,  in  Germany;  for  in  both  of 
those  countries  the  medical  expert  is  an  officer  of  the  law,  and  his  investigation 
of  judicial  questions  within  his  province  is  conducted  under  the  sanction  of  an 
oath  and  of  his  official  responsibility. 

We  cannot  follow  Dr.  Walshe  in  the  concluding  portion  of  his  Address,  which 
relates  to  the  opinion  of  the  lay  world  concerning  the  relationship  of  medicine 
to  the  general  march  of  civilization.  He  shows  that  in  this  respect,  medicine 
has  not  been  justly  dealt  with,  and  especially  in  regard  to  the  ardent  love  of 
truth  and  the  zealous  pursuit  of  it  which  has  distinguished  the  cultivators  of 
this  science.  Alone,  of  lay  historians,  he  says,  the  late  Mr.  Buckle  has  even 
attempted  to  render  our  science  and  art  the  justice  which  they  may  claim, 
although  he  failed  in  'his  object  because  his  powers  of  mind  were  essentially  de- 
ductive and,  therefore,  inapt  to  comprehend  a  science  which  is  purely  inductive. 
We  believe  that  the  imperfect  appreciation  of  medicine  by  historians  arises  from 
several  causes,  but  chiefly  from  this  that  it  directly  acts  on  individuals  and  not 
on  masses.  The  bulk  of  history  is  composed  of  politics  and  war,  and  its  chief 
actors  are  statesmen  and  soldiers.  It  is  not  only  a  modern,  but  a  very  recent, 
innovation  to  introduce  into  general  histories  an  account  of  the  intellectual  ele- 
ments of  civilization.  Even  literature  and  art,  although  so  generally  attractive, 
and  possessing  such  splendid  monuments  to  attest  and  chronicle  their  progress, 
have  hitherto  depended  chiefly  upon  special  histories  for  a  record ;  and  we  can- 
not, therefore,  complain  that  the  share  which  the  medical  profession  has  had  in 
civilizing  mankind  should  have  been  usually  overlooked  by  the  historians  of 
national  advancement.  Henceforth,  the  creative  and  preservative  rather  than 
the  destructive  powers  will  demand  the  chief  attention  of  writers  who  propose 
to  chronicle  the  development  of  national  greatness,  and  among  them  it  will  be 
impossible  to  neglect  the  influence  of  medicine  in  all  its  branches,  as  one  of  the 
chief  agencies  employed  to  protect,  perpetuate,  and  strengthen  society. 

Mr.  Paget's  Address  on  the  Management  of  Patients  after  Surgical  Opera- 
tions has  all  the  characteristics  which  eminently  distinguish  the  works  of  English 
Surgeons,  and  which  were  so  prominent  in  those  of  Sir  Astley  Cooper,  and  Sir 
B.  Brodie.  They  may  be  comprised  in  two  words,  common  sense.  This  national 
trait  is  one  more  apt  to  be  displayed  in  surgery  than  in  medicine ;  that  is  to  say 
in  material  and  mechanical  procedures  which  are  open  to  the  senses  in  their  opera- 
tion and  results,  and  rather  than  in  the  management  of  remedies,  whose  mode  of 
action  is  doubtful,  and  is  rendered  doubly  uncertain  by  the  obscurity  of  the  in- 
terim] condition  they  are  intended  to  cure.  Here  the  faculties  required  are 
more  generally  the  rational  as  distinguished  from  the  instinctive ;  the  questions 
to  be  solved  often  demand  the  highest  powers  of  ratiocination  for  their  solution. 
Doubtless,  Mr.  Paget  is  fully  able  to  solve  successfully  the  most  intricate  of 
these ;  but  in  the  present  instance  he  has  confined  himself  almost  exclusively  to 
common  and  practical  topics.  While  he  urges  the  propriety  of  favouring  union 
of  wounds  by  the  first  intention,  whenever  the  appropriate  conditions  for  it 
exist,  he  dissuades  from  persisting  too  pertinaciously  in  the  attempt,  lest  ery- 


1863.]      Annual  Meeting  of  the  British  Medical  Association.  113 


sipelas,  purulent  absorption,  &c,  may  be  favoured.  Kepose  and  cleanliness  he 
aptly  terms  the  two  essentials  of  cure,  but  ne'xt  to  these  is  diet.  Equally  remote 
from  incendiary  methods  and  starvation  plans,  he  counsels  nutritious  and  va- 
ried food,  according  to  the  patient's  taste  and  habits,  and  particularly  inveighs 
against  "  the  monotomy  of  mutton."  It  is  a  judicious  remark,  that  we  are  too 
apt  to  consider  reaction  after  shock  as  a  mark  of  disease,  and  as  requiring  a 
lowering  treatment ;  whereas,  he  views  this  process  as  a  proof  of  power  in  the 
constitution,  and,  therefore,  not  to  be  unduly  interfered  with.  He  does  not, 
however,  fail  to  speak  of  a  reaction  whose  very  violence  depends  upon  weakness 
from  anaemia,  nervousness,  exhaustion,  &c,  and  which  must  be  treated  with 
stimulants,  including  opium,  until  the  shock  is  passed.  The  mortality  after 
operations  appears  to  Mr.  Paget  to  be  very  indeterminate,  or  rather  undeter- 
mined, and  particularly  because  care  enough  is  not  taken  to  discriminate  between 
deaths  caused  by  operations  and  those  which  follow  operations  and  occur  in- 
dependently of  them  or  in  spite  of  them.  By  this  way  of  reckoning  the  aggre- 
gate of  deaths  set  to  the  account  of  operations  would  be  very  materially  reduced ; 
but  if  it  could  be  honestly  determined  the  interests  of  science  and  art  would 
both  be  promoted.  Mr.  Paget  lauds  anaesthetics,  and  thinks  that  chloroform 
is  unjustly  charged  with  deaths  which  should  be  attributed  to  shock, even  "after 
operations  of  no  great  severity."  Unhappily  the  deaths  from  this  agent  are 
numerous  in  which  no  shock  existed  save  that  which  the  anaesthetic  itself  pro- 
duced. He  next,  speaks  of  phlebitis,  inflamed  lymphatics,  erysipelas,  pyaemia, 
putrid  infection,  and  tetanus,  as  influencing  the  result  of  operations.  These 
affections  depend  upon  the  condition  and  actual  morbid  proclivities  of  the  pa- 
tients who  are  submitted  to  surgical  operations,  and  their  development  is 
determined  by  the  shock  or  other  conditions  of  the  operations  performed.  In 
reference  to  rigors  which  so  generally  usher  in  the  secondary  consequences  of 
operations,  he  suggests  that  their  explanation,  which  is  acknowledged  to  be  very 
difficult,  may  be  sought  in  their  analogy  to  convulsive  affections.  In  support 
of  this  opinion  he  cites  several  cases  in  which  epileptiform  convulsions  took 
the  place  of  chill,  and  refers  to  the  frequency  with  which  such  attacks  usher  in 
febrile  affections,  especially  in  children.  But  however  caused,  their  origin,  he 
maintains,  is  constitutional,  and  dependent,  along  with  the  conditions  which  they 
introduce,  upon  a  morbid  state  of  the  blood  and  tissues  ;  and  he  notices  several 
among  the  forms  and  grades  of  traumatic  pyaemia,  some  of  which  are  rapidly 
fatal,  with  phenomena  indicating  a  rapid  and  thorough  disorganization  of  the 
circulating  fluids,  and  others  present  various  degrees  of  gravity  from  the  severest 
to  the  most  transient  and  slight.  He  very  properly  classes  them  with  the  true 
eruptive  fevers,  as  blood  diseases.  As  for  the  remedies  for  these  fatal  and 
troublesome  affections,  he  acknowledges  that  although  quinine  will  sometimes 
cut  short  the  attack,  he  finds  only  one  thing  that  he  can  call  remedial  for  the 
whole  disease,  pyaemia,  and  that  is,  a  profuse  supply  of  fresh  air. 

The  Address  in  Physiology,  by  Dr.  Sharpey,  contains  a  review  of  the  leading 
features  and  incidents  which  have  marked  the  progress  of  the  science  in  recent 
times.  The  great  benefits  that  have  arisen  from  the  establishment  of  schools  of  phy- 
siology are  pointed  out,  especially  as  these  institutions  are  managed  in  Germany. 
In  this  connection  the  lecturer  felt  obliged  to  descend  to  an  argument  addressed 
to  the  well-meaning  persons  who  indulge  in  "indignant  but  misdirected  declama- 
tion against  experiments  upon  animals."  This  reminds  us  of  a  similar  con- 
descension upon  the  part  of  several  eminent  writers  in  defending  the  use  of 
anaesthetics  against  the  cavils  of  those  who  could  not  bear  to  see  parturition 
deprived  of  its  pangs,  lest  the  fulfilment  of  the  prophetic  curse  on  Mother  Eve 
should  be  hindered  of  its  accomplishment.  For  such  PecksnifSan  objectors  the 
most  appropriate  argument  is  contempt.  We  need  not  follow  Dr.  Sharpey  in 
his  exposition  of  the  value  of  microscopical  investigations,  and  of  numerical 
determination  in  physiology,  nor  in  his  sketch  of  the  progress  of  physiological 
chemistry.  The  physiology  of  the  nervous  system  ;  that  of  reproduction  ;  the 
recent  advances  in  histology  ;  and  the  prevailing  views  of  the  forces  of  the  living 
organism,  are  briefly  considered,  and  some  of.  the  more  important  of  recent  ac- 
quisitions to  positive  knowledge  are  clearly  presented.  We  are  struck,  how- 
ever, with  the  absence  of  all  allusion  to  certain  names,  discoveries,  and  views, 
which  we  suspect  that  his  audience  were  prepared  to  hear  mentioned.    A.  S. 


174  Bibliographical  Notices.  [Jan. 


Art.  XXVI. — Pathological  and  Practical  Observations  on  Diseases  of  the  Ab- 
domen, comprising  those  of  the  Stomach  and  other  parts  of  the  Alimentary 
Canal,  (Esophagus,  Caecum,  Intestines,  and  Peritoneum.  By  S.  0.  Haber- 
shon,  M.  D.,  Lond.  F.R.C.P.,  Senior  Assistant  Physician  to  Guy's  Hospital, 
&c.  &c.  Second  edition,  considerably  enlarged  and  revised.  London :  John 
Churchill,  1862.    8vo.  pp.  594. 

The  early  demand  for  a  new  edition  of  this  work,  shows  that  the  profession 
accord  with  us  in  the  favourable  opinion  we  expressed  of  it  on  its  first  appear- 
ance (see  No.  of  this  Journal  Jan.  1860,  p.  198).  In  the  present  edition  every 
portion  of  the  work  has  been  carefully  revised,  and  not  only  have  large  additions 
been  made  to  the  text,  but  a  number  of  cases  are  given  to  further  illustrate 
the  phases  of  disease ;  and  a  very  interesting  chapter  on  peritonitis  has  been 
appended. 

In  the  different  chapters  of  the  work  frequent  reference  is  made  to  the  disease 
of  the  serous  investment  of  the  intestines,  but  in  the  chapter  appended  to  the 
present  edition,  the  author  specially  reviews  the  general  forms  of  peritonitis — 
describes  the  pathological  appearances  presented — enumerates  the  symptoms 
by  which  it  is  indicated — the  causes  which  produce  it,  and  points  out  the  treat- 
ment best  calculated  for  its  removal. 

Dr.  H.  first  describes  the  progress  of  peritonitis  from  its  earliest  pathological 
appearance — congestion  of  its  capillary  vessels  with  loss  of  its  smooth  and 
shining  character — to  its  termination  in  effusion  of  serum  or  pus,  and  of  lymph, 
causing  adhesions  of  the  abdominal  contents,  or  thickening  of  the  membrane 
from  effusion  of  fibrin  within  its  tissue,  &c.  &c. 

The  symptoms  of  acute  peritonitis,  Dr.  Habershon  remarks,  "  are  generally 
very  characteristic,  as  when,  for  instance,  the  stomach  and  appendix  cosci  are 
perforated  by  ulceration,  sudden  intense  pain  comes  on,  the  patient  is  '  doubled 
up,'  unable  to  move,  and  lies  with  the  legs  flexed ;  the  countenance  expresses 
the  intensity  of  the  suffering,  as  well  as  the  serious  nature  of  the  disease ;  the 
distress  and  pain  are  evident  in  the  features,  the  eyes  are  sunken,  the  face  is 
pallid,  the  abdomen  very  shortly  becomes  distended,  tender,  and  tympanitic  ;  no 
pressure  can  be  borne,  and  even  the  weight  of  the  bedclothes  becomes  insuffer- 
able ;  the  pulse  is  small,  compressible,  and  if  reaction  take  place,  from  the  first 
sudden  collapse,  it  becomes  more  hard  and  frequent,  wiry  ;  the  bowels  are 
generally  confined,  especially  at  the  early  stage  of  the  acute  disease,  but  some- 
times towards  the  close  of  the  malady  diarrhoea  may  supervene.  The  urine  is 
scanty,  and  if  the  vesical  peritoneum  be  involved,  retention  often  takes  place. 
If  the  peritoneal  surface  of  the  stomach  be  implicated,  vomiting  is  a  frequent 
and  distressing  symptom,  and  green  bilious  fluid  is  ejected.  The  mind  may  be 
conscious  and  strong  throughout,  even  when  the  powers  of  life  are  fast  failing, 
and  the  pulse  scarcely  perceptible  at  the  wrist. 

"  In  many  cases  of  perforation  the  patient  scarcely  rallies  from  the  first  sud- 
den collapse,  and  death  takes  place  in  five  to  ten  hours  after  the  onset  of  the 
disease ;  in  other  instances,  however,  the  signs  of  febrile  excitement  are  more 
evident,  as  shown  by  heat  of  skin,  especially  of  the  abdomen,  by  thirst,  and  by  a 
frequent  and  hard  pulse.  If  the  disease  tend  to  an  unfavourable  termination, 
the  prostration  increases,  the  patient  is  restless,  the  tongue  dry  and  brown,  the 
pulse  compressible,  failing,  and  irregular ;  the  extremities  become  cold,  a 
clammy  sweat  breaks  out,  hiccough  comes  on,  and  then  death  follows,  the 
patient  often  remaining  sensible  till  the  close,  and  the  subsidence  of  pain,  as 
life  is  ceasing,  occasionally  gives  to  the  superficial  observer  a  false  hope  of 
recovery.  On  the  contrary,  when  the  vomiting  subsides,  the  pain  and  distension 
lessen,  the  countenance  becomes  less  haggard  and  dejected,  the  pulse  soft  and 
less  frequent,  but  tolerably  firm,  and  especially,  when  the  patient  has  refreshing 
sleep,  we  may  regard  the  immediate  danger  as  less  imminent.  Gradually  all  the 
symptoms  may  disappear,  and  the  patient  completely  recover,  with  perhaps 
some  peritoneal  adhesions  and  thickening.  It  may  be  that  effusions  take  place, 
which  are  more  gradually  absorbed,  or  become  very  persistent ;  again,  if  fecal 


1863.] 


Habershon,  Diseases  of  the  Abdomen. 


175 


extravasation  have  occurred,  repeated  attacks  of  local  peritonitis,  with  hectic 
fever,  follow,  or  renewed  general  inflammation  destroys  the  life  of  the  patient." 

The  'paroxysmal  occurrence  of  the  pain  in  strumous  peritonitis  is  noticed  by 
Dr.  H.  This  paroxysmal  character  is  often  very  striking.  We  have  seen  the 
pain  recur  with  the  regularity  of  a  paroxysm  of  intermittent,  the  patient  during 
the  interval  being  so  entirely  free  from  suffering  as  to  lead  to  the  hope  that  the 
disease  was  arrested ;  but  this  delusion  would  be  dispelled  at  the  regular  period 
by  the  recurrence  of  pain  resembling  a  severe  attack  of  colic.  It  may  be  ob- 
served also  that  in  this  affection  "  the  bowels  are  often  irregular,  the  stomach 
sometimes  irritable,  the  tongue  red  and  injected,  the  patient  fretful,  and  as  the 
intestines  become  matted  together  by  adhesions,  the  viscera  move  en  masse,  and 
a  doughy  sensation  is  communicated  on  manipulation.  Or  these  strumous  and 
inflammatory  adhesions  may  be  local,  simulating  abdominal  tumours.  The 
indications  of  disease  are  also  associated  with  general  strumous  cachexia,  and 
are  often  complicated  with  pulmonary  disease.  Too  frequently  hectic  super- 
venes, and  this  is  especially  the  case  when  fecal  abscess  has  been  produced,  and 
the  hope  of  ultimate  recovery  is  then  almost  taken  away.  In  strumous  peri- 
tonitis also  the  pain  may  be  very  slight,  whilst  effusion  gradually  takes  place  to 
a  considerable  extent,  as  we  sometimes  find  in  children  after  measles,  &c,  or 
excessive  tympanitis  may  be  produced  without  any  acute  pain." 

The  diagnosis  of  peritonitis  is  not  always  easy.  The  pain  may  not  only  be 
absent  on  account  of  the  peculiar  character  of  the  disease,  but  the  patient  may 
be  rendered  unconscious  of  it  from  cerebral  oppression  or  from  the  dyspnoea  and 
distress  of  pulmonary  and  cardiac  disease.  The  author  points  out  the  following 
means  of  distinguishing  peritonitis  from  the  painful  conditions  of  the  abdomen 
for  which  it  may  be  mistaken  : — 

"  1st.  Flatulent  colic.  The  pain  and  distension  are  in  this  disease  sometimes 
very  severe,  the  countenance  may  be  haggard  and  distressed,  and  collapse  some- 
times results ;  but  there  is  not  the  tenderness  of  peritoneal  inflammation,  the 
symptoms  are  less  persistent,  the  pulse  less  affected,  the  collapse  rarely  so  pro- 
found. 2d.  In  hysterical  affections  of  the  abdomen,  the  pain  is  very  superficial, 
and  firm  pressure  can  frequently  be  borne,  whilst  the  patient  almost  shrieks 
before  the  hand  has  reached  the  surface  ;  the  countenance  does  not  express  the 
distress  of  serious  organic  disease,  the  pulse  may  be  almost  unaffected ;  still,  in 
this  disease,  we  have  seen  the  patient  bled  from  the  arm  to  syncope,  with  the 
idea  that  acute  disease  existed.  3d.  The  vomiting  and  sudden  pain  of  perforated 
intestine  are  sometimes  mistaken  for  gall-stone ;  but  the  latter  disease  is  free 
from  the  acute  tenderness  and  distension  of  peritonitis.  4th.  Neuralgic  pain 
from  disease  of  the  spine,  of  a  functional  or  organic  character,  often  simulates 
peritonitis ;  but  here,  also,  there  is  an  absence  of  tenderness  on  pressure  of  the 
abdomen,  of  distension  and  tympanitis,  as  well  as  of  the  general  expression  of 
peritoneal  disease  ;  the  pain  is  situated  in  the  course  of  the  spinal  nerves,  and 
often  extends  over  the  crest  of  the  ilium  in  the  course  of  the  last  dorsal  nerve, 
or  into  the  groin  and  testicle  in  the  course  of  the  genito-crural  nerve  ;  there  are 
also,  generally,  some  indications  of  spinal  disease  in  local  pain  of  the  vertebras, 
with  modified  motion  and  sensibility  of  the  lower  extremities,  and  loss  of  power 
of  the  sphincter  muscles.  5th.  Suppuration  of  the  abdominal  parietes  is  at  an 
early  stage  very  difficult  to  distinguish  from  peritonitis.  6th.  The  pain  from  the 
distension  consequent  on  the  enlargement  of  abdominal  tumours  and  effusions 
may  easily  be  mistaken  for  peritonitis,  as,  for  instance,  in  aneurism,  in  ovarian 
and  cancerous  tumours,  and  in  dropsies ;  but  in  these  cases,  as  we  have  before 
said,  peritoneal  disease  is  often  set  up  in  the  progress  of  the  malady.  7th. 
During  the  course  of  peritonitis,  the  muscular  fibres  of  the  bladder  sometimes 
fail  to  contract,  apparently  from  loss  of  power,  and  the  urine  is  retained,  thus 
closely  simulating  simple  retention  of  urine ;  on  the  contrary,  we  have  also  wit- 
nessed distension  of  the  urinary  bladder  from  enlarged  prostate  or  other  cause, 
producing  pain  which  resembled  peritonitis,  and  which  had  been  sent  to  the 
hospital  as  a  case  of  abdominal  tumour." 

Dr.  H.  divides  the  causes  of  peritonitis  into  three  classes  : — 

"  1.  Peritonitis  produced  by  the  extension  of  disease  from  adjoining  viscera, 
or  excited  by  direct  injury,  including  cases  of  perforation  of  viscera,  extra- 


176 


Bibliographical  Notices. 


[Jan. 


vasation,  violence,  &c.  2.  Peritonitis  connected  with  blood  changes,  as  when 
inflammation  of  the  serous  membrane  occurs  in  the  course  of  albuminuria, 
Pyaemia,  puerperal  fever,  erysipelas,  <fcc.  3.  Peritonitis  caused  by  general  nutri- 
tive changes  of  the  system;  which  have  been  followed  by  acute  or  chronic  dis- 
ease of  the  peritoneum,  such  as  struma,  cancer,  &c. ;  and  comprising  also  those 
cases  in  which  the  circulation  of  the  peritoneum  has  been  so  altered  by  con- 
tinued hyperemia  (modifying  its  state  of  growth),  that  very  slight  exciting 
causes  suffice  to  induce  acute  mischief,  as  occurs  in  peritonitis  with  cirrhosis, 
disease  of  the  heart,  &c." 

Of  501  cases  of  peritonitis  met  with  in  the  post-mortem  examinations  during 
a  period  of  twenty-five  years  at  Guy's  Hospital,  261  were  of  peritonitis  from 
direct  extension,  94  were  connected  with  blood  change,  and  146  with  general  or 
local  perverted  nutrition. 

An  important  cause  of  peritonitis  is  perforation  of  the  intestine  into  the  peri- 
toneal sac,  and  this  occurred  in  the  501  cases  56  times.  10  times  from  hernia ; 
9  from  disease  of  stomach  ;  15  from  fever-ulceration  of  ileum  ;  4  from  strumous 
disease ;  11  from  disease  of  caecum  and  appendix ;  1  from  cancer  of  vagina ;  4 
from  cancer  of  colon  ;  2  from  ovarian  adhesion. 

With  regard  to  the  treatment  of  peritonitis,  Dr.  H.  thinks  that  our  best  guide 
is  the  consideration  of  the  origin  of  the  disease,  whether  it  arise,  "  1st,  from  ex- 
tension of  disease  from  adjoining  viscera,  or  from  perforation  and  injuries  ;  2d, 
from  blood  changes,  such  as  occur  in  albuminuria,  pyaemia,  and  erysipelas,  &c. ; 
3d,  from  almost  imperceptible  changes  or  deficiencies  in  general  nutrition  mo- 
difying the  state  of  the  general  health,  as  in  struma,  cancer,  and  climacteric 
changes  ;  or  from  the  hyperemia  of  the  peritoneum,  consequent  on  cirrhosis  and 
chronic  disease  of  the  heart  and  lungs,  when  upon  very  slight  exciting  causes, 
acute  mischief  follows.  In  the  first  form,  if  perforation  have  taken  place,  per- 
fect rest  is  exceedingly  important,  in  diminishing  extravasation,  and  in  localizing 
the  peritoneal  mischief ;  purgative  medicines  of  all  kinds  should  be  avoided,  and 
also  stimulants,  which  are  often  unfortunately  given  at  once,  before  a  medical 
practitioner  sees  the  patient,  in  perforation  of  the  intestine.  This  injudicious 
attempt  to  relieve  pain  by  purgatives,  carminatives,  and  stimulants,  may  deprive 
the  patient  of  the  hope  of  recovery ;  for,  as  we  have  before  said,  we  have  seen 
castor  oil  floating  in  the  peritoneal  cavity.  Food,  also,  should  be  abstained 
from,  or  only  a  few  spoonfuls  administered  to  relieve  thirst ;  in  more  chronic 
forms,  not  arising  from  perforation,  food  of  a  fluid  and  bland  kind  is  only  admis- 
sible ;  and  even  when  the  more  active  symptoms  have  subsided,  the  return  to 
solid  forms  of  aliment  must  be  very  cautiously  made.  When  there  are  symp- 
toms of  failing  power,  stimulants  in  small  quantities  may  be  given,  but  are  best 
combined  with  demulcent  food,  as  brandy  with  arrowroot,  &c. 

"As  regards  medicinal  treatment,  we  believe  the  plan  recommended  by  Dr. 
Stokes  and  Dr.  Graves  to  be  of  the  greatest  value,  not  only  in  cases  of  perfora- 
tion of  the  intestine,  but  where  the  peritoneum  is  acutely  inflamed  from  the 
direct  extension  of  disease.  It  consists  in  the  administration  of  opium  in  full 
and  repeated  doses  ;  and  its  beneficial  result  arises  from  its  favouring  rest  of  the 
intestines  and  the  localization  of  the  mischief,  from  the  mitigation  of  suffering 
which  it  affords,  whilst  at  the  same  time  it  alleviates  nervous  prostration  and 
collapse,  and  facilitates  reparative  action.  In  many  instances  the  opiate  plan 
may  be  combined  with  local,  and  sometimes  even  with  general  depletion ;  ano- 
dyne remedies  may  be  applied  externally,  or  counter  irritants,  as  cantharides 
and  turpentine.  Local  peritonitis  is  thus  greatly  relieved  by  local  depletion  and 
external  applications,  as  when  produced  by  ovarian  and  caecal  disease ;  but 
blisters  are  of  value,  especially  in  those  instances  in  which  repeated  attacks  of 
peritonitis  occur.  Mercury,  either  in  the  form  of  gray  powder,  calomel,  blue 
pill,  or  as  mercurial  inunction,  is,  we  believe,  injurious  in  all  these  cases  of 
acute  direct  peritonitis.  It  tends  to  prevent  adhesion,  it  excites  peristaltic 
action,  it  promotes  ulcerative  action,  it  increases  the  depression  consequent  on 
the  disease,  which  is  often  the  immediate  cause  of  death,  and  lastly,  it  renders 
the  intestinal  contents  more  fluid,  thereby  increasing  extravasation.  We  are 
well  aware  that  many  instances  of  acute  peritonitis  from  diseased  caecum,  from 
enteritis,  and  from  ovarian  disease,  recover  after  mercury  has  been  given ;  but 


1863.] 


Habersiion,  Diseases  of  the  Abdomen. 


as  far  as  the  causes  we  have  enumerated  can  be  any  guide,  and  from  extensive 
experience  in  these  cases,  we  strongly  deprecate  its  use. 

"  Effervescent  medicines  generally  increase  the  painful  distension  of  the  abdo- 
men, but  diaphoretics  and  salines  are  sometimes  of  value  when  combined  with 
opium.  * 

"  In  the  subsequent  treatment  we  must  not  be  too  desirous  of  inducing  action 
from  the  bowels,  and,  when  necessary,  gentle  enemata  are  better  than  purga- 
tives administered  by  the  mouth. 

"  When  the  more  active  symptoms  have  subsided,  opium  may  be  continued 
with  vegetable  tonics  or  with  quinine.  If  fluid  effusions  have  formed,  iodide  of 
potassium  and  diuretics  may  be  advisable,  and  the  abdominal  glands  may  then 
be  beneficially  stimulated  by  an  occasional  dose  of  gray  powder  or  calomel. 
Preparations  of  iron  are  not  generally  well  borne  in  the  convalescence  from 
acute  peritonitis.  It  will  often  be  found  that  as  the  health  becomes  established 
the  fluid  effusion  rapidly  disappears ;  in  other  cases  the  repeated  application  of 
counter  irritants  may  be  required,  and  sometimes  it  is  well  to  remove  the  serum 
by  paracentesis. 

"  In  the  peritonitis  of  albuminuria  the  best  treatment  consists  in  the  relief  of 
the  general  disease  by  diaphoretic  medicines,  counter  irritation  and  cupping  on. 
the  loins,  and  by  free  evacuation  of  the  bowels  ;  but  mercurial  preparations  very 
readily  affect  the  system,  producing  severe  salivation,  without  corresponding 
benefit.  When  effusion  becomes  extreme,  it  is  better  to  attempt  its  removal  by 
puncturing  the  thighs  and  by  purgatives  than  by  directly  emptying  the  serous 
cavity.    Hot-air  baths  are  sometimes  of  great  service. 

"  In  the  treatment  of  the  peritonitis  of  pyaemia  and  erysipelas  the  local  dis- 
ease is  to  be  less  regarded  than  the  general  one,  nor  should  we  attempt  to  cure 
the  peritonitis  of  this  kind  by  depletion  and  mercurial  preparations.  Opium  and 
salines,  with  the  free  use  of  stimulants,  are  apparently  the  best  remedial  agents 
we  can  employ.  Typhoid  symptoms  too  frequently  come  on,  and  precede  a  fatal 
result. 

"  In  puerperal  peritonitis  the  same  plan  of  treatment  may  be  adopted.  In 
some  cases  the  blood  becomes  affected  by  the  absorption  of  pus ;  or  pelvic 
phlebitis  and  cellulitis  are  followed  by  the  peritoneal  disease;  and,  from  the 
beneficial  effect  following  the  internal  administration  of  tincture  of  the  sesqui- 
chloride'  of  iron  in  erysipelas  and  diphtheritic  disease  of  the  throat,  Dr.  Heslop 
has  recommended  the  same  remedy  in  puerperal  peritonitis,  as  being  a  disease 
closely  allied  in  character.  Those  cases  which  we  have  seen  recover  have 
apparently  been  benefited  by  thoroughly  washing  away  uterine  discharges  by 
the  free  use  of  opium,  and  by  stimulants ;  but  we  are  quite  prepared  to  hear 
further  reports  of  the  good  results  of  the  tincture  of  the  sesquichloride.  In 
puerperal  peritonitis  the  use  of  turpentine  internally  has  been  recommended,  and 
has  been  followed  sometimes  by  a  beneficial  resuk. 

"  In  the  treatment  of  acute  peritonitis  in  struma,  the  same  rules  ought  to  be 
borne  in  mind  as  in  the  treatment  of  strumous  pneumonia.  Opium  is  of  value 
not  only  in  relieving  the  pain  and  the  great  nervous  prostration  so  constant  in 
disease  of  the  abdomen,  but  it  also  facilitates  the  recovery  of  the  injured  struc- 
ture. Warmth,  anodyne  applications,  the  use  of  local  depletion  may  be  used ; 
purgatives  should  be  avoided,  and  rest  strictly  maintained ;  but  mercurial  pre- 
parations, given  so  as  to  affect  the  mouth,  are  as  injurious  in  this  form  of  stru- 
mous complication  as  in  any  other,  and  it  is  not  necessary  to  recur  to  mercury 
for  an  aperient  remedy,  nor  to  prevent  the  opiates  from  checking  secretion. 

"  In  the  more  chronic  forms  of  the  disease,  the  means  best  calculated  to  re- 
move the  local  malady  are  those  suited  for  the  removal  of  the  general  state ; 
such  as  nourishment  as  far  as  it  can  be  borne,  cod-liver  oil,  steel  as  the  iodide, 
steel  wine,  the  iodide  of  potassium,  alkalies,  &c.  Occasional  counter  irritants 
may  be  used,  and  moderate  pressure  on  the  abdomen  employed  to  promote  the 
absorption  of  serous  effusions ;  an  elastic  bandage,  strips  of  plaster,  as  the  ad- 
hesive or  the  belladonna  plaster,  may  be  thus  applied ;  in  some  instances  in 
which  I  have  used  the  ammoniacum  plaster  with  mercury,  the  intolerable  itch- 
ing which  was  produced  compelled  the  removal  of  the  application.  Residence 
at  the  sea-side  greatly  facilitates  recovery  in  these  cases.  In  slow  strumous 
No.  LXXXIX.— Jan.  1863.  12 


178 


Bibliographical  Notices. 


[Jan. 


effusion,  especially  in  young  persons,  after  peritonitis,  it  is  often  extremely  diffi- 
cult to  produce  absorption,  and  paracentesis  is  sometimes  advisable. 

"  Peritonitis  with  cancerous  disease  is  always  associated  with  enfeebled  power 
and  diminished  functional  activity.  Eemedies  such  as  diuretics  have  very  little 
effect  in  promoting  the  absorption  of  fluid,  and  any  measured  which  still  further 
diminish  strength  appear  to  increase  dropsical  effusion.  To  sustain  the  powers 
of  life  by  every  available  means  is  the  best  preventive  against  this  result.  If 
acute  symptoms  supervene,  the  opiate  plan  of  treatment  must  be  followed  with 
rest  and  bland  nutritious  diet.  If  paracentesis  be  performed,  temporary  relief 
may  be  obtained;  but  more  frequently  the  patient  very  rapidly  declines,  and  we 
then  find  that  the  whole  of  the  diseased  peritoneal  surface  has  increased  in  vas- 
cularity, and  lymph  is  poured  out. 

"  Peritonitis  with  cirrhosis  is  generally  found  in  persons  who  have  been  of 
intemperate  habits;  the  arteries  are  often  diseased,  and  the  kidneys  may  be 
granular  and  atrophied.  At  an  early  stage  of  the  disease,  when  the  diet  can  be 
regulated,  and  the  excretory  functions  of  the  liver,  the  kidneys  and  the  skin 
stimulated  to  increased  action,  the  symptoms  may,  in  a  great  degree,  be  allevi- 
ated ;  and  when  acute  peritonitis  is  set  up  with  cirrhosis,  no  class  of  cases  are 
more  benefited  by  the  judicious  use  of  the  ordinary  remedies  for  peritonitis, 
namely,  local  depletion,  and  mercurials  with  opium,  on  account  of  the.  stimulant 
effect  which  mercurials  have  on  the  excretory  glands;  but  all  the  good  effect  of 
mercury  may  be  attained  without  that  remedy  being  used  so  as  to  produce 
salivation." 

In  chronic  peritonitis  associated  with  advanced  cirrhosis,  Dr.  H.  does  not 
hold  out  hopes  of  success  from  any  course  of  treatment.  He  considers  that  our 
measures  in  this  condition  can  at  best  be  only  palliative.  "Some,"  he  remarks, 
"  have  recommended  mild  mercurial  salivation  before  tapping,  to  prevent  the 
supervention  of  acute  symptoms ;  but  we  have  no  experience  in  such  an  appli- 
cation of  this  medicine,  and  believe,  that  if  tapping  be  really  necessary,  mercurial 
salivation  would  be  detrimental,  and  would  increase  the  exhaustion  which  often 
follows  the  operation,  or  that  the  mercurial  cachexia  would  lead  to  the  speedy 
reaccumulation  of  the  fluid.  Mercurial  frictions  are  less  objectionable  when 
used  with  moderation ;  and  minute  doses  of  blue  pill,  with  tonics,  as  quinine,  or 
with  aperients,  are,  in  many  instances  of  chronic  peritonitis  from  hepatic  disease, 
of  great  service.  Other  remedies  may  also  be  tried,  as  diuretics,  iodide  "of  potas- 
sium, nitro-hydrochloric  acid,  &c,  but  the  persistent  congestion  of  the  vena  portae 
interferes  with  their  absorption  and  with  their  beneficial  action.  Nearly  the 
same  remarks  apply  to  the  treatment  of  peritonitis  coming  on  in  the  course  of 
chronic  disease  of  the  heart  and  of  the  lungs.  In  these  cases  I  never  recom- 
mend paracentesis,  unless  compelled  by  the  urgent  distress  from  enormous  dis- 
tension." 

Dr.  H.  does  not  believe  that  the  benefit  generally  ascribed  to  mercury  in  the 
treatment  of  acute  peritonitis  is  an  established  fact,  a  doubt  in  which  we  must 
say  we  do  not  participate,  though  we  are  free  to  confess  that  a  portion  of  the 
relief  which  has  followed  its  use  may  be  due  to  the  opium  with  which  it  is  usually 
combined. 


Art.  XXVII. — Anatomy  of  the  Arteries  of  the  Human  Body,  Descriptive  and 
Surgical,  with  the  Descriptive  Anatomy  of  theHcart.  By  John  Hatch  Power, 
M.  D.,  Fellow,  and  Member  of  Council,  of  the  Koyal  College  of  Surgeons ;  Pro- 
fessor of  Descriptive  and  Practical  Anatomy  in  the  Royal  College  of  Surgeons; 
Surgeon  to  the  City  of  Dublin  Hospital,  etc.  Authorized  and  adopted  by  the 
Surgeon  General  of  the  United  States  Army  for  Use  in  Field  and  General 
Hospitals.    Philadelphia  :  J.  B.  Lippincott  and  Co.,  18G2,  12mo.  pp.  401. 

A  short  notice  of  the  English  edition  of  this  work  was  given  in  the  number  of 
this  Journal  for  April,  1861.  As  the  work  has  now  been  republished  in  this 
country,  and  more  particularly  as  it  appears  under  the  authority  of  the  Surgeon 


1863.] 


Power,  Arteries  of  the  Human  Body. 


1T9 


General,  and  has  been  adopted  by  him  for  use  in  the  Field  and  General  Military 
Hospitals  of  the  United  States,  a  more  extended  notice  seems  to  be  required. 

In  the  preface  the  author  says:  "The  present  work  has  been  undertaken 
chiefly  with  the  view,  of  assisting  the  student  whilst  engaged  in  the  study  of 
practical  anatomy, *and  of  affording  him  such  practical  information  in  connec- 
tion with  the  anatomy  of  the  arterial  system,  as  may  be  of  advantage  to  him 
long  after  his  studies  have  been  completed. 

"  For  the  purpose  of  effecting  these  desirable  objects,  I  have  endeavoured  to 
simplify  as  much  as  possible  the  anatomical  details,  and  to  bring  together  such 
material  facts  in  relation  to  the  operations  upon  the  principal  arteries  of  the 
body,  as  may  lead  to  correct  conclusions  relative  to  the  treatment  of  the  various 
accidents  and  diseases  to  which  these  vessels  are  exposed." 

He  subsequently  says,  that  he  has  not  overlooked  the  fact  that  there  are  many 
practitioners,  particularly  those  in  rural  districts,  who  do  not  possess  any  oppor- 
tunity of  refreshing  their  memories  upon  anatomical  points  by  actual  dissection, 
and  that  he  is  not  without  hope  that,  to  such,  the  present  volume  may  afford 
some  useful  hints  as  to  the  relations  of  those  bloodvessels  which,  from  time  to 
time,  may  become  the  subject  of  their  operations. 

The  description  by  Dr.  Power,  of  the  anatomy  of  the  heart  is  clear,  suc- 
cinct, and  correct.  The  directions  given  to  guide  in  its  dissection  are  not, 
however,  as  numerous  or  as  judicious  as  they  should  be.  For  example,  to  see 
the  internal  surface  of  the  right  auricle,  the  student  is  advised  to  make  one  inci- 
sion in  a  vertical  direction  through  the  front  of  the  auricle,  connecting  the 
orifices  of  the  superior  and  inferior  venae  cavse,  and  a  second  in  a  slightly  curved 
direction,  the  convexity  directed  downwards,  commencing  at  the  lower  part  of 
the  right  auricular  appendix,  and  terminating  in  the  superior  extremity  of  the 
preceding  incision.  This  purpose  is  effected  much  better  by  a  transverse  inci- 
sion from  the  auricle  to  the  inferior  vena  cava,  and  a  vertical  one  beginning  at 
the  superior  vena  cava  and  meeting  the  other  in  its  centre.  Again,  to  expose 
the  interior  of  the  right  ventricle  a  V-shaped  incision,  one  branch  of  which  is  on 
the  right  edge  of  the  heart,  and  the  other  along  the  anterior  fissure,  is  decidedly 
preferable  to  an  incision  in  the  direction  of  the  axis  of  the  heart,  and  close  to 
the  septum  ventriculorum.  The  figures  by  which  the  anatomy  of  the  heart  is 
illustrated  are  remarkably  coarse. 

In  describing  the  arteries,  Dr.  Power  gives  an  excellent  account  of  the  origin, 
the  situation,  the  direction,  the  form,  the  anastomoses,  and  the  relations  of 
each  particular  vessel.  Of  the  manner  in  which  arteries  terminate,  and  of  the 
tissues  of  which  they  are  composed,  not  one  word,  however,  is  said.  The  student 
is  left  in  entire  ignorance  as  to  whether  the  arteries  are  continuous  with  the 
veins,  or  any  other  bloodvessels,  and  as  to  whether  they  possess  one  coat  or  a 
dozen.  There  is  another  point,  moreover,  of  infinite  practical  importance,  to 
which  no  reference  is  made,  and  this  is,  the  general  relations  existing  through- 
out.the  body,  between  the  arterial  system,  and  the  veins,  the  nerves,  the  aponeu- 
roses, the  muscles,  and  the  bones.  A  knowledge  of  them  is  of  the  greatest 
service  to  the  surgeon  in  assisting  in  the  recollection  of  the  particular  relations 
of  every  particular  artery.  As  these  general  relations  are  quite  commonly 
Omitted  in  works  on  anatomy,  it  may  be  well  to  enter  somewhat  into  their  con- 
sideration, in  order  to  set  forth  more  clearly  the  value  we  attach  to  them,  and 
the  importance  of  not  omitting  them  in  a  work  of  the  pretensions  of  the  one 
before  us. 

There  is  but  one  vein  accompanying  the  arterial  trunk  of  the  body,  the  neck, 
the  head,  and  the  origin  of  the  limbs ;  for  the  arteries  distributed  to  the  arm,  the 
forearm,  and  the  hand,  and  also  to  the  leg  and  the  foot,  there  are  two.  When 
there  are  two  accompanying  veins,  the  artery  is  always  between  them  ;  the  veins 
being  either  to  the  right  and  left,  or  before  and  behind.  The  knowledge  of  the 
relative  situation  of  these  vessels  is  of  great  importance  in  surgery,  for  it  is  not 
always  easy  to  distinguish  an  artery  from  a  vein,  and  it  is  very  important  to 
make  the  distinction  when  hemorrhage  must  be  arrested  by  the  application  of  a 
ligature.  There  can  be  no  uncertainty  in  the  selection  of  the  vessel,  if,  after 
having  exposed  the  three  parallel  tubes,  the  operator  recollects  that  the  one 
placed  between  the  others  is  always  part  of  the  arterial  system.    In  those  places 


180 


Bibliographical  Notices. 


[Jan. 


where  the  artery  is  accompanied  by  only  one  vein,  the  vein  is  generally  the  more 
superficial.  Thus,  the  internal  jugulars  are  nearer  the  skin  than  the  primitive 
carotids,  the  subclavian  veins  are  more  anterior  than  the  corresponding  arteries, 
and  the  axillary  and  the  crural  veins  are  more  internal  (towards  the  centre  of 
the  body)  than  the  arteries  of  the  same  name. 

The  arteries  are  always  more  deeply  seated  than  the  nerves  by  which  they  are 
accompanied.  Thus,  the  cords  of  the  brachial  plexus  are  nearer  the  skin  than 
the  subclavian  artery ;  the  median  and  cubital  nerves  cover  the  axillary  artery ; 
the  median  nerve  passes  before  the  brachial  artery  and  places  itself  then  on  its 
internal  side ;  the  radial  and  ulnar  nerves  are  situated,  one  outsfde  of  the  radial 
artery,  the  other  inside  of  the  ulnar,  so  that  these  vessels  are  nearer  the  axis 
of  the  forearm,  and  the  nerves  nearer  the  integuments.  On  the  thigh,  the  cru- 
ral nerve  occupies  likewise  the  external  and  anterior  side  of  the  femoral  artery, 
and  the  internal  saphenous  nerve  runs  along  the  anterior  portion  of  the  same' 
vessel.  To  be  brief,  then,  the  law  determining  the  respective  positions  of  the 
arteries  and  the  veins,  is  also  that  regulating  the  relations  of  the  nerves  with  the 
arteries  ;  and  this  law  is  itself  derived  from  the  constant  tendency,  presented  by 
the  arteries,  to  hide  themselves  among  the  most  deeply  seated  parts.  The  gene- 
ral relations  of  the  arteries,  the  veins,  and  the  nerves,  can  be  expressed  by  say- 
ing that  an  incision  practised  upon  one  of  the  limbs  for  the  purpose  of  dividing 
these  different  organs,  would  meet  first  the  nerves,  then  the  veins,  and  lastly  the 
arteries. 

The  general  relations  of  the  arteries  with  the  aponeuroses  of  the  limbs ;  with 
the  muscles,  particularly  those  projecting  under  the  skin  by  which  the  course  of 
an  artery  can  often  be  decided  just  as  from  the  study  of  bony  eminences,  articular 
lines  are  recognized ;  and  with  the  bones,  regulating  the  most  favourable  places 
for  exercising  compression,  are  of  very  great  practical  interest.  The  general 
relations  of  arteries  with  the  common  cellular  tissue  of  the  body,  are  not  to  be 
overlooked.  This  tissue  is  close,  when  the  artery  is  contiguous  to  a  vein,  and  on 
the  contrary  very  loose,  at  all  points  where  it  is  in  contact  with  fibrous,  muscular, 
or  bony  surfaces.  From  this  it  happens  that  the  vein  and  the  artery  are  asso- 
ciated in  the  various  displacements  they  undergo ;  and  it  is  owing  to  this  also 
that  in  applying  a  ligature  the  separation  of  the  artery  from  the  vein  is  the  most 
difficult  part  in  isolating  the  vessel,  and  that  when  there  are  two  veins  the  diffi- 
culty is  much  increased.  This  cellular  tissue  around  the  vessels  is  traversed  by 
numerous  small  bloodvessels,  that'supply  the  walls  of  the  arteries ;  and  when  an 
artery  is  isolated  to  apply  a  ligature,  these  vessels  are  torn  as  well  as  the  sur- 
rounding cellular  tissue;  hence,  it  is  so  important,  in  isolating  an  artery  not  to 
surpass  the  limits  necessary  to  the  success  of  the  operation. 

We  believe  that  the  importance  of  the  consideration  of  the  general  relations 
of  the  arteries  will  be  obvious  to  all,  and  that  we  may  justly  complain  at  not 
finding  any  reference  to  them  in  the  book  here  presented  to  us. 

The  figures  illustrating  the  anatomy  of  the  arterial  system  are  more  neatly 
executed  than  those  representing  the  heart. 

Beside  the  account  of  the  anatomy  of  the  different  arteries,  a  description  is 
given  of  the  mode  of  ligating  certain  amongst  them.  Here,  again,  we  think, 
explanation  should  have  been  given  of  the  action  of  the  ligature,  together  with 
general  rules  to  guide  in  its  application.  It  is  only  by  a  perfect  understanding 
of  general  principles  and  general  rules  that  a  particular  operation  can  be  safely 
and  skilfully  practised.  In  a  work  designed  for  students,  wherein  the  operation 
of  placing  a  ligature  upon  certain  arteries  is  described,  it  seems  to  us  a  great 
omission  to  have  said  nothing  of  the  three  coats  of  the  arteries,  of  the  action  of 
threads  of  different  thickness  upou  these  coats,  of  the  effect  of  arresting  the 
circulation  of  the  blood,  of  the  pathological  processes  that  take  place  in  the 
ligated  vessel,  and  of  the  instruments  that  are  required  in  the  operation,  and 
the  manner  in  which  they  are  to  be  used  in  seizing,  isolating,  and  surrounding 
the  artery  with  the  thread. 

As  to  the  several  operations  described  by  Dr.  Power  for  ligating  the  particu- 
lar arteries,  they  are  by  no  means  such  as  a  student  could  readily  and  success- 
fully practise.  If  we  take,  for  example,  the  lingual  artery,  we  are  told  here  that 
it  "may  be  exposed  by  an  incision  extending  transversely  from  the  os  hyoides  to 


1863.]  Paine,  The  Institutes  of  Medicine.  181 

the  margin  of  the  sterno-mastoid  muscle.  The  skin,  platysma,  and  fascia  being- 
divided,  the  glistening  tendon  of  the  digastric  muscle  is  brought  into  view ; 
beneath  this,  and  lower  down,  is  the  hypo-glossal  nerve,  much  duller  in  its  ap- 
pearance than  the  tendon ;  whilst  the  artery  will  be  found  situated  still  lower  and 
a  little  deeper  than  the*  nerve"  (p.  99)  .  A  much  safer  and  surer  direction  for 
reaching  the  artery  would  be  to  direct  an  incision  to  be  made  one  and  a  half 
inches  long,  two  lines  above  the  great  horn  of  the  hyoid  bone,  and  parallel  to  it, 
through  the  skin  and  platysma  muscle ;  the  lower  border  of  the  submaxillary 
gland  is  thus  reached.  The  gland  should  be  turned  up  out  of  the  way,  as  a 
muscle  would  be,  and  beneath  it  the  shining  tendon  of  the  digastric  muscle  is 
seen,  embraced  by  the  stylo-hyoides.  Detaching  these  muscles  from  the  hyoid 
bone,  and  turning  them  up,  the  hypo-glossal  nerve  is  reached ;  just  below  this 
nerve,  divide  transversely  the  hypo-glossal  muscle,  and  the  artery  is  found. 
.  When  treating  of  the  brachial  and  the  femoral  arteries  some  mention  is  made 
by  Dr..  Power  of  the  employment  of  compression  in  the  treatment  of  aneurism 
of  these  vessels  ;  but  the  principles  by  which  external  pressure  is  to  be  methodi- 
cally employed,  the  various  instruments  to  be  used,  and  the  satisfactory  results 
to  be  thereby  attained,  are  not  related.  This  is  the  more  astonishing  inasmuch 
as  Dr.  Power's  work  was  originally  published  in  Dublin,  where  so  much  has  been 
done  in  this  mode  of  treating  aneurism.  We  can  find  no  mention  whatever  made 
of  the  treatment  of  aneurism  by  forced  flexion  of  the  limb,  nor  of  the  adoption 
of  this  position  for  the  arrest  of  the  arterial  circulation  in  cases  of  hemorrhage 
in  the  lower  portions  of  the  upper  and  lower  extremities. 

The  reflections  we  have  made  upon  Dr.  Power's  book,  as  one  professing  to 
treat  of  the  descriptive  anatomy  of  the  heart,  and  of  the  descriptive  and  surgi- 
cal anatomy  of  the  arteries,  must  apply,  with  still  greater  propriety  to  the  same 
work  when  announced  as  a  surgical  anatomy  of  the  arteries,  and  as  issued  for 
the  use  of  surgeons  on  the  field  of  battle  and  in  army  hospitals.  In  such  a  work 
a  long  account  of  the  anatomy  of  the  heart,  of  the  distribution  of  the  branches 
of  the  internal  carotid,  of  the  circulation  of  the  blood  in  the  liver,  and  of  the 
pulmonary  arteries,  is  not  only  unnecessary,  but  the  book  is  increased  in  size, 
and  therefore  more  cumbersome  and  less  easy  of  reference.  This  will  be  found 
the  more  annoying,  when  the  work'  shall  be  consulted  in  a  hurry,  as  we  must 
•imagine  it  is  intended  to  be  when  used  on  the  field  of  battle,  by  the  absence  of 
an  index  to  its  contents. 

In  conclusion  we  may  say  that  this  work  is  a  good  manual  for  the  use  of  stu- 
dents in  pursuing  their  dissections ;  imperfect  as  a  guide  to  aid  the  surgeon  in 
performing  operations,  and  defective  and  unsatisfactory  as  a  work  for  hurried 
reference.  We  cannot,  therefore,  notwithstanding  the  high  estimation  in  which 
we  hold  the  approbation  of  the  surgeon-general  of  the  U.  S.  army,  but  regard 
it  as  unsuited  for  the  purpose  for  which  it  has  been  issued  in  this  country. 

W.  F.  A. 


Art.  XXYIIL—  The  Institutes  of  Medicine.  By  Martyn  Paine.  M.  D.,  LL.  D., 
Professor  of  the  Institutes  of  Medicine  and  Materia  Medica  in  the  University 
of  the  City  of  New  York,  etc.  etc.  etc.  Seventh  edition.  8vo.  pp.  1130. 
New  York,  1862.    Harper  &  Brothers. 

We  cordially  welcome  this  new  edition  of  Dr.  Paine's  Institutes.  The  con- 
tinued demand  for  the  work  must  be  received  as  evidence  that  it  is  duly 
appreciated  by  a  large  number  of  the  reading  and  reflecting  portion  of  the 
medical  profession  of  our  country.  These  Institutes  are  not  only  replete  with 
truths  in  relation  to  physiology,  pathology,  and  therapeutics,  respectively, 
but  in  the  doctrines  inculcated  by  the  author  in  each  of  these  departments  of 
medicine,  will  be  found  many  thoughts  of  a  highly  suggestive  character,  which, 
if  carried  out  to  their  legitimate  results,  cannot  fail  to  lead  to  a  recognition 
of  the  important  truth  that,  in  all  his  ministrations,  the  physician  has  to  do 
with  a  living  vital  organism,  all  of  whose  abnormal  states  are  to  be  received  as 


182 


Bibliographical  Notices. 


[Jan. 


the  results,  immediate  or  remote,  of  disturbances  of  vitality — for  the  correction 
of  which  those  remedial  agents  alone  can  be  effective  as  act  immediately  upon 
living  organs,  and  are  capable  of  bringing  about- such  a  modification  of  their 
disturbed  vitality  as  shall  be  adapted  to  restore  their  actions,  and,  as  far  as 
practicable,  their  tissues  to  their  normal  conditions.    .  * 

The  present  edition  of  the  Institutes  does  not  differ  in  any  material  degree 
from  its  immediate  predecessor,  but  seems  to  be  printed  from  the  same  stereo- 
type plates.  Some  brief  foot  notes  have  been  added,  and  a  few  addenda,  which 
suggested  themselves  after  the  first  impression  was  stricken  off,  are  presented 
in  the  form  of  an  appendix  at  the  end  of  the  volume.  D.  F.  C. 


Art.  XXIX. —  The  Hospital  Steward's  Manual:  for  the  Instruction  of  Hos- 
pital Stewards,  Ward  Masters,  and  Attendants,  in  their  Several  Duties. 
Prepared  in  strict  accordance  with  existing  regulations  and  the  customs  of 
service  in  the  armies  of  the  United  States  of  America,  and  rendered  authorita- 
tive by  order  of  the  Surgeon  General.  By  Joseph  Janvier  Woodward,  M.  D., 
Assistant  Surgeon  U.  S.  A.,  Member  of  the  Academy  of  Natural  Sciences 
of  Philadelphia,  etc.  Philadelphia:  J.  B.  Lippincott  &  Co.,  1862.  12mo. 
pp.  324. 

This  little  work,  after  having  been  approved  by  a  board  of  medical  officers, 
has  been  adopted  by  the  Surgeon  General  of  the  U.  S.  Army  as  a  guide  to  the 
stewards  and  other  attendants  of  U.  S.  military  hospitals. 

Its  contents  are  divided  into  five  parts,  treating  respectively  of  hospital  stew- 
ards and  other  hospital  attendants,  with  a  general  outline  of  their  duties  ;  of  the 
discipline,  police,  and  general  supervision  of  military  hospitals ;  of  provisions 
and  hospital  stores,  and  the  preparation  of  food  in  hospitals ;  of  medical  sup- 
plies and  the  general  arrangement  and  management  oHhe  dispensary,  with  some 
explanations  in  regard  to  compounding  and  distributing  prescriptions ;  and  of 
dressings  and  those  operations  in  minor  surgery  performed  by  a  steward  or  other 
hospital  attendant, 

A  book  of  this  kind  was  much  needed,  and  no  one  could  be  better  qualified 
for  the  undertaking  than  the  author  of  the  present.  It  is  well  printed  in  large 
clear  type,  and  well  illustrated.  At  page  305  is  a  wood-cut,  where  the  left 
hand  is  engaged  in  doing  what  Dr.  Woodward  tells  us  the  right  hand  should 
do,  and  what  the  right  hand  generally  does  do.  This  is  all  we  have  been  able 
to  discover  not  exactly  as  it  should  be  in  this  most  useful  little  work. 

W.  F.  A. 


Art.  XXX. — A  few  Remarks  on  the  Primary  Treatment  of  Wounds  re- 
ceived in  Battle :  a  Report  to  the  Surgeon  General  of  Massachusetts.  By 
George  H.  Gay,  M.  D.,  Surgeon  at  the  Massachusetts  General  Hospital. 
Boston,  1862.    8vo.  pp.  8. 

The  remarks  on  the  primary  treatment  of  gunshot  wounds,  published  in  this 
little  pamphlet,  arc  in  strict  accordance  with  the  teachings,  derived  from  expe- 
rience, of  the  best  military  surgeons  in  all  countries. 

They  contain  nothing  original  in  regard  to  the  treatment  of  such  injuries ; 
nothing  but  what  every  one  should  know  well  before  attempting  the  practice  of 
his  profession. 

Nevertheless  we  believe  the  publication  a  useful  one,  or  rather  one  that  would, 
be  a  useful  one,  if  a  great  number  of  the  surgeons  in  this  country  would  read  it, 
and  read  it  too  with  a  belief  that  others  may  have  a  better  knowledge  than 
themselves  of  what  is  right  in  medicine.  W.  F.  A. 


1863.] 


183 


QUARTERLY  SUMMARY 

OF  THE 

IMPROVEMENTS  AND  DISCOVERIES 

IN  THE 

MEDICAL  SCIENCES. 


ANATOMY  AND  PHYSIOLOGY. 

1.  The  Deep  Origin  of  the  Facial  Nerve. — The  Gazette  Medicate  de  Paris 
(Nos.  22,  24,  30,  34,  36,  and  38,  1862)  contains  an  elaborate  memoir  by  M.  A. 
Vulpian,  Prof,  agrege  of  Med.  Fac.  of  Paris,  communicated  to  the  Biological 
Society,  entitled,  "Experimental  Researches  respecting  the  Effects  of  Lesions 
of  the  Floor  of  the  Fourth  Yentricle,  and  especially  on  the  Influence  of  these 
Lesions  on  the  Facial  Nerve."  The  following  are  his  conclusions  relative  to  the 
deep  origin  of  the  facial  nerve : — ■ 

1.  The  facial  nerve  derives  its  principal  origin  from  a  point  of  the  encephalic 
isthmus  situated  at  the  level  of  the  floor  of  the  fourth  ventricle,  and  at  a  very 
small  distance  from  the  surface  of  that  floor.  In  the  dog,  the  point  of  origin 
is  placed  about  two  millimetres  astride  the  central  furrow,  at  the  junction  of  the 
anterior  two-fifths  with'the  posterior  three-fifths  of  the  flow.  2.  This  point  of 
origin  is  the  true  centre  and  focus  of  the  reflex  actions  of  the  nerve.  "Vivisec- 
tions prove  that  it  is  only  necessary  for  this  centre  to  be  intact,  and  the  nerve 
in  communication  with  it,  in  order  that  reflex  actions  of  the  facial  muscles  may 
be  produced.  3.  The  deep  origins  of  the  right  and  left  nerves  communicate  by 
commisural  structures.  4.  Certain  root-like  fibres  directly  traverse  the  median 
raphe,  and  consequently  decussate  on  the  median  line.  But  these  fibres  are 
very  few  in  number,  and  we  cannot  confidently  assign  them  as  the  cause  of  the 
cross-influence  of  the  hemispheres  on  the  facial  muscles.  This  influence  is  doubt- 
less chiefly  made  possible  by  the  considerable  decussation  between  the  elements 
of  the  two  halves  of  the  encephalic  isthmus  at  the  median  raphe.  It  is  not 
proved  that  any  determinate  part  of  the  decussating  elements  belongs  specially 
to  the  facial  nerves. 

2.  Epithelium  of  the  Air-Ceils. — It  is  generally  believed  that  epithelium  is 
not  present  in  the  air-cells  of  the  lungs.  Dr.  0.  J.  Eberth,  of  Wlirzburg,  does 
not  participate  in  this  belief;  in  an  interesting  paper  in  Virchow's  Archives 
(Bd.  xxiv.  Heft  5  and  6)  he  gives  the  following  as  the  result  of  his  investigations. 

"1.  The  air-cells  of  the  lung  at  their  bases  and  side-walls  possess  a  delicate 
interrupted  epithelium,  which  particularly  occupies  the  meshes  of  the  vessels. 
Only  the  narrow  free  edges  of  the  divisions  of  the  air-cells  are  without  epithelium. 

"  2.  The  compactness  of  the  epithelial  layer  is  dependent  on  the  extent  of  the 
air-cells,  and  the  degree  of  fulness  of  the  vessels. 

"  3.  The  projections  of  the  vessels  which  are  found  between  the  epithelial  cells 
have  hitherto  led  to  the  assumption  of  a  complete  epithelium. 

"  4.  The  nuclei  lying  in  the  capillary  meshes,  conceived  sometimes  to  be  those 
of  the  epithelium,  at  others  to  be  those  of  the  stroma,  are  the  nuclei  of  the 
epithelium." 


184 


Progress  op  the  Medical  Sciences. 


[Jan. 


3.  Identity  of  Hcematoidin  and  Bilifulvin. — Dr.  Max  Jaffe,  of  Berlin,  after 
alluding  to  the  researches  of  Zencker,  Brucke,  Valentine,  Kiihne,  &c,  on  the 
same  subject,  states  that  he  has  obtained  crystals  in  a  chloroform  solution  of 
bile,  which  in  form  and  all  known  reactions  closely  agree  with  hsemato'idin.  He 
then  proceeds  to  describe  an  examination  of  a  cerebral  apoplectic  cicatrix, 
which  proved  that  hasmatoidin  and  bilifulvin  were  identical. 

This  cicatrix,  which  was  of  a  yellowish-brown  colour,  and  showed  under  the 
microscope  a  large  number  of  crystals  of  haemato'idin,  was  dried  in  a  water-bath 
and  cut  into  small  pieces.  A  chloroform  extract  was  made,  and  was  then  moist- 
ened with  a  few  drops  of  absolute  alcohol,  by  which  the  action  of  the  chloroform 
was  apparently  facilitated.  The  extract  which  contained  the  cerebral  fat  was 
of  a  deep  yellow  colour.  The  chloroform  extract  was  then  gently  evaporated 
down  in  a  watch-glass,  and  for  twenty-four  hours  was  placed  in  a  darkened  place 
(for  fear  of  oxidation  changes,  which,  in  the  case  of  bilifulvin  solutions,  take 
place  in  the  sunlight,  and  quickly  produce  changes  of  colour),  and  then  examined 
microscopically.  It  was  found  to  consist  of  transparent,  golden-yellow,  beauti- 
fully formed  crystals,  corresponding  accurately  to  haemato'idiu  in  form. 

On  freeing  the  crystals  by  ether  from  fat,  a  portion  of  them  became  dissolved 
therein  (pure  ether  as  well  as  pure  alcohol  partially  dissolves  bilifulvin),  the  re- 
maining crystals  being  soluble  with  tolerable  facility  in  solution  of  carbonate  of 
soda.  The  yellow  solution  became  green  during  filtration.  A  small  remaining 
portion  was  treated  with  sulphuric  acid  and  examined,  and  the  crystals  then 
showed  the  well  known  colour-play  of  biliary  colouring  matter.  Similar  changes 
were  observed  in  the  chloroform  solution  on  the  addition  of  sulphuric  acid. 

From  these  observations  on  the  microscopical  and  chemical  character  of  the 
crystals,  the  author  concludes  that  hsematoidin  and  bilifulvin  are  identical,  and 
he  points  out  the  bearing  which  this  statement  has  upon  our  views  regarding 
the  changes  of  blood-cells  in  the  liver. 

Examinations  of  other  apoplectic  changes  in  portions  of  brain  which  had  been 
long  immersed  in  spirit  did  not  disclose  crystals  of  bilifulvin. 

The  fat  which  remained  after  distillation  of  the  yellow  chloroform  extract- 
assumed  the  shape  of  margaric  acid  crystals,  and  probably  mechanically  hindered 
the  formation  of  bilifulvin  crystals. — Brit,  and  For.  Med.-Chir.  Review,  Oct. 
1862,  from  Virchow's  Archiv.,  1861,  Bd.  xxiii. 


MATERIA  MEDICA  AND  PHARMACY. 

4.  Action  and  Uses  of  Codeia. — Dr.  Aran,  Professor  Agr6ge  at  the  Faculty 
of  Medicine,  and  Physician-in-Chief  to  the  Hospital  St.  Antoine,  has  lately  made 
some  experiments  with  codeia,  and  says  that  as  yet  he  has  employed  "  this  alka- 
loid only  to  obtain  calm  and  sleep,  but  from  the  ten  or  twelve  cases  I  have  wit- 
nessed I  have  been  able  to  discover  in  this  agent  sedative  and  narcotic  properties, 
which  in  my  estimation  place  it  in  the  first  rank  amongst  the  best  remedies  of 
this  kind  existing.  To  recapitulate  in  a  few  words  the  impression  this  medica- 
ment has  made  upon  me,  I  will  tell  you  that  the  codeia  seems  to  me  to  contain 
the  most  marvellous  and  efficacious  properties  of  opium.  Inferior  to  morphia 
for  calming  pains,  for  this  reason  only,  that  it  must  be  given  in  larger  doses  to 
patients ;  it  has,  however,  over  morphia,  a  marked  superiority  in  that  respect, 
that  it  never  occasions  a  heavy  and  agitated  sleep ;  that  it  does  not  bring  on 
perspiration  or  eruptions  of  the  skin,  nor  trouble  the  digestion  ;  that  it  produces 
no  obstinate  constipation,  no  desire  to  vomit  nor  any  vomiting.  For  all  these 
considerations  codeia  appears  to  me  to  be  destined  to  become  of  great  service 
iu  the  nervous  diseases  of -the  stomach,  and  I  can  tell  you  that  we  have  obtained 
with  it  some  calm  in  cases  of  gastrodynia,  which  had  defied  all  other  means, 
belladonna  included. 

"But  it  is  especially  as  a  means  of  procuring  calm  and  restoring  sleep  that 
the  codeia  seems  to  me  called  to  occupy  an  important  place  in  therapeutics. 


1863.] 


Materia  Medica  and  Pharmacy. 


185 


Those  stubborn  and  harassing  coughs  of  bronchitis,  and  particularly  of  con- 
sumption, those  violent  pains  of  rheumatism,  gout,  and  the  organic  affections, 
of  cancer,  for  instance,  which  disturb  the  sleep,  and  frequently  deprive  the 
patients  of  the  least  moments  of  repose,  are  all  forgotten  in  the  midst  of  the 
calm  and  agreeable  sleep  which  codeia  procures. 

"  I  have  witnessed  two  very  conclusive  cases  of  incurable  cancerous  tumours, 
for  which  no  means  of  relief,  at  all  lasting,  had  been  found.  One  of  these 
tumours,  of  an  enormous  size,  almost  filled  the  pelvis,  and  produced  on  the  pas- 
sage of  the  sciatic  nerve  pains  returning  at  about  8  o'clock  P.M.,  and  with  such 
an  intensity  as  to  force  cries  from  the  patient,  who  could  only  become  calm  but 
towards  the  morning,  when  she  would  fall  asleep,  overcome  with  fatigue.  Two 
centigrammes1  of  codeia  produced  the  first  day  a  calm  so  complete  that  the  pa- 
tient thought  herself  cured,  and  for  the  first  time  since  a  month  she  was  able  to 
take  a  somewhat  copious  meal,  her  appetite  having  returned  for  the  first  time. 
During  the  twelve  days  I  attended  this  person,  the  pains  were  almost  nul,  and 
as  soon  as  they  reappeared  the  invalid  mastered  them  with  a  few  centigrammes 
of  codeia;  it  became,  however,  necessary  to  increase  the  dose  by  degrees,  and 
from  two  centigrammes  the  patient  increased  the  dose  to  ten  and  twelve  centi- 
grammes. 

"  To  explain  how  so  small  a  dose  produced  a  calm  so  complete,  I  must  observe 
that  her  weak  state  rendered  her  very  sensitive  ,  to  the  action  of  codeia,  which, 
on  the  other  hand,  appears  to  me  quite  able  to  be  given  from  the  first  in  a  much 
larger  dose  than  morphia.  For  example,  we  have  seen  the  dose  of  five  centi- 
grammes of  it  in  the  syrup  calming  the  pains  of  gastrodynia  without  leaving  the 
slightest  trace  of  narcotism  ;  and  one  of  our  patients  takes  at  present  every  day 
fifteen  centigrammes  of  codeia  without  any  bad  effect.  -This  invalid,  who  has 
long  made  use  of  opium  and  morphia,  establishes  between  those  agents  and 
codeia  a  difference  quite  to  the  advantage  of  the  latter,  which  does  not  agitate 
her  at  all."— Ed.  Med.  Joum.,  Sept.  1862. 

5.  Use  of  Malt  and  Beer  in  Tlierapeutics. — Malt  has  been  long  since  used  in 
Germany,  and  particularly  in  Berlin,  as  a  popular  remedy  for  bronchial  catarrh 
and  dyspepsia.  It  is.  however,  not  more  than  a  year  since  the  German  phy- 
sicians began  to  prescribe  it  after  Itustendt,  who  first  announced  its  advan- 
tages. 

In  France,  brewers  were  accustomed  to  use  a  tisane  of  malt  for  bronchitis  and 
rheumatism,  and  lately  Dr.  Fremy  has  tried  this  therapeutic  agent  for  many 
months  on  patients  in  the  Beaujon  Hospital. 

Dr.  Fremy  received  direct  from  a  Berlin  brewery  the  medicinal  preparations 
of  the  beer,  the  powder  of  malt  and  the  malt  beer,  and  with  these  he  made  his 
experiments.  According  to  comparative  analysis  by  Ohevrier,  essential,  differ- 
ences exist  between  such  malt  and  that  in  use  at  the  Paris  breweries.  In  the 
first  place,  the  Paris  malt  shows  no  trace  of  diastase,  while  that  of  Berlin  con- 
tains forty-five  centigrammes  in  every  thousand  grammes. 

The  latter  also  contains  a  considerable  quantity  of  lupuline,  of  which  there  is 
no  trace  of  the  former,  as  well  as  a  portion  of  cane  sugar,  which  renders  it  more 
pleasing  to  the  taste.  We  must  consequently  conclude  that  the  method  of  pre- 
paring such  malt  is  different  from  that  followed  at  Paris.  The  malt  beer  is  its 
concentrated  essence.  It  has  the  taste  of  certain  English  beers,  such  as  Scotch 
ale,  is  tolerably  frothy,  and  very  aromatic.  The  malt  is  taken  in  the  form  of  a 
hot  decoction,  and  may  be  mixed  with  milk.  The  beer  may  be  taken  hot  or  cold, 
and  at  dinner. 

Fremy  experimented  with  malt  in  that  hopeless  disease,  pulmonary  tubercu- 
losis. Of  sixty-four  phthisical  patients  submitted  to  the  remedy  not  one  was 
cured.  Five  of  them  left  the  hospital  so  considerably  improved  that  they  believed 
themselves  well,  but  auscultation  proved  that  the  cure  was  far  from  complete. 
In  the  remainder,  the  local  state  continued  as  before,  the  phenomena  of  auscul- 
tation remained  unaltered ;  while  in  both  cases  the  general  phenomena  of  phthisis, 
viz.,  perspiration  and  diarrhoea,  were  modified  for  the  better.    But  if,  in  decided 


One  centigramme  is  equal  to  one-sixth  grain. 


186 


Progress  of  the  Medical  Sciences. 


[Jan. 


phthisis,  malt  gave  equivocal  or  no  results,  it  was  otherwise  in  suspected  pul- 
monary catarrh,  in  incipient  tubercles,  in  which  cases  it  was  employed  with  suc- 
cess. 

A  man  of  25  years  of  age  had  a  cough  for  many  years,  had  visibly  become 
thin,  and  upon  auscultation  and  percussion  presented  clear  signs  of  tubercular 
deposit  on  the  apex  of  the  two  lungs.  He  had  derived  no  benefit  from  the  use 
of  cod-liver  oil,  nor  from  any  other  of  the  usual  remedies,  when,  by  Fr6my's 
advice,  he  was  treated  with  beer  and  powder  of  malt.  After  two  months  of  this 
treatment,  it  is  attested  by  Fremy,  that  his  cough  had  disappeared,  respiration 
was  more  fully  performed  ;  the  resonance  had  become  less  obscure ;  the  mur- 
mur gentle  and  equal ;  his  appetite  was  excellent ;  his  strength  and  flesh  had 
returned. 

The  decoction  of  malt  produced  the  highest  benefit  in  febrile  bronchitis  with 
hoarseness,  and  the  symptoms  were  sometimes  subdued  in  forty-eight  hours.  It 
was  equally  useful  in  chronic  pulmonary  catarrhs,  and  especially  in  those  which 
produce  grave  dyspeptic  accidents  in  old  people.  The  malt  in  these  cases 
rapidly  excited  the  digestive  powers,  and  cured  the  bronchitis.  In  dyspepsia, 
also,  it  was  no  less  successful,  after  the  gravelly  complication  had  been  re- 
moved. 

From  such  observations.  Signor  Fr6my  concludes  that  malt  possesses  a  double 
therapeutic  virtue ;  the  one,  laxative,  demulcent ;  the  other,  tonic,  restorative, 
analeptic.  In  fact,  according  to  experiments  by  Bidault,  if  powdered  malt  be 
macerated  for  an  hour  in  water  at  75  cent.,  a  liquid  is  obtained  charged  with 
syrup  of  starch  (glucose) ,  and  what  is  more  extraordinary  is,  that  in  this  liquid 
is  found  free  gluten.  To  this  syrup  of  starch  the  decoction  of  malt  owes  its 
laxative  power,  and  in  that  it  would  differ  little  or  nothing  from  Hippocratic 
tisane;1  but  the  gluten,  which  is  free  in  it,  and  in  a  state  which  offers  the 
greatest  facility  to  being  absorbed  by  the  digestive  organs,  the  diastase,  and  the 
bitter  principle  of  the  lupuline,  give  an  analeptic  virtue  to  the  malt,  and  make 
an  anti-dyspeptic  of  it.  These  united  virtues  render  malt  a  valuable  medicine, 
one  of  great  utility  in  numerous  cases,  and  which  ought  not  to  be  surrendered 
entirely  to  vulgar  medicine. — Translated  by  M.  Donovan,  for  Dublin  Med.  Press, 
from  Lo  Sperimentale,  Fas.  vii. 

6.  On  Some  Local  Anaesthetics. — Messrs.  Dyce  Duckworth,  and  Richard 
Davy,  record  (Edinburgh  Medical  Journ.,  July,  1862)  the  results  of  some  in- 
teresting experiments,  made  by  them  with  certain  local  anaesthetics.  They  em- 
ployed chloroform  in  the  form  of  liquid  and  vapour;  ammonia  in  vapour  and 
liquid  ;  chloracetization  and  ice. 

They  relate  the  following  experiments  made  with  chloroform : — ■ 
"  Exp.  1.  Vapour. — We  applied  the  vapour  to  our  arms  in  test  tubes  for 
periods  of  ten  and  fifteen  minutes.  In  about  three  minutes  a  feeling  of  coldness 
was  experienced  in  the  parts  operated  upon,  the  skin  becoming  reddened.  This 
sensation  merged  into  one  of  slight.irritation,  but  never  amounted  to  pain.  In 
from  ten  to  fifteen  minutes,  on  pricking  the  arm,  sensibility  was  decidedly 
diminished,  though  not  abrogated.  Subsequently  no  local  signs  of  irritation 
remained. 

"  Exp.  2.  Topical  Application  of  Chloroform  in  the  form  of  Liquid. — We 
applied  chloroform  on  lint,  and  in  test  tubes,  to  the  backs  of  our  hands  and  arms 
for  periods  varying  from  ten  to  thirteen  minutes.  Yerysoon  an  irritative  action 
commenced  in  the  part,  gradually  increasing  and  becoming  slightly  painful  for 
about  seven  minutes,  when  the  pain  began  to  diminish,  and  a  sense  of  heat  re- 
mained in  the  part,  with  well-marked  redness.  On  pricking  the  arm  in  one  case, 
it  was  found  totally  insensible  to  the  stimulus  for  the  space  of  half  a  minute, 
after  which  sensibility  gradually  returned.  In  the  other  case,  total  anaesthesia 
was  not  produced— the  application,  however,  being  maintained  for  ten  minutes 
only.    The  sensibility  was  nevertheless  greatly  diminished.    In  both  cases  per- 


1  Hippocrass  is  a  kind  of  a  spiced  wine  formerly  much  in  use  in  England  and 
other  countries. — Translator. 


1863.] 


Materia  Medica  and  Pharmacy. 


187 


sistent  redness  remains,  the  line  of  pressure  being  especially  well-marked,  and 
the  parts  continue  super-sensitive  if  touched." 

The  following-  experiments  were  made  with  ammonia. 

"  Vapour. — Mr.  Davy  applied  the  vapour  of  the  liquor  ammonia?  fortissimus 
to  the  back  of  his  arm  for  ten  minutes ;  very  slight  tingling  ensued.  No  anaes- 
thesia nor  signs  of  irritation. 

"Liquid. — He  next  applied  a  mixture  of  equal  parts  of  liquor  ammonia?  for- 
tissimus and  water  to  the  flexor  surface  of  his  forearm  in  a  wide  test-tube  for 
ten  minutes.  Irritation  commenced  immediately,  and  increased  gradually  up  to 
0the  time  of  removal,  when  perfect  anaesthesia  resulted.  This,  as  in  the  case  of 
liquid  chloroform,  quickly  disappeared.  The  cuticle  was  found  to  be  detached 
from  the  cutis  vera.    Irritation  continued  at  the  part  for  ten  days  afterwards." 

With  regard  to  chloracetization  they  say:  This  "was  introduced  by  M. 
Fournie,  who  communicated  his  results  to  the  French  Academy  not  very  long 
ago.  He  announces  that  the  most  perfect  anaesthesia  can  be  produced  by  mix- 
ing equal  parts  of  chloroform  and  glacial  acetic  acid  in  a  vessel,  filling  it  half-full, 
maintaining  the  mixture  at  the  temperature  of  the  hand,  and  the  room  in  which 
the  experiment  is  performed  at  a  temperature  of  62°  Fahr.  The  mixture  is  to 
be  applied  to  the  sound  skin ;  the  part  to  be  acted  on  being  marked  off  by  a 
piece  of  diachylon  plaster.  In  five  minutes,  under  these  circumstances,  total 
anaesthesia  is  to  be  looked  for.  Upon  the  rapidity  of  its  action,  and  the  slight 
inconveniences  occasioned  thereby,  are  based  the  merits  of  this  method.  We 
were  much  interested  in  reading  Mr.  Fournie's  announcement,  and  determined 
to  give  it  a  fair  trial.  We  therefore  complied  with  all  his  directions,  and  pro- 
ceeded to  try  chloracetization.  Two  drachms  of  glacial  acetic  acid  and  a  drachm 
and  a  half  of  chloroform  were  put  into  an  ounce  test-tube,  warmed  to  the  heat  of 
the  hand,  and  then  applied  to  the  skin  of  the  forearm.  In  from  ten  to  fifteen 
seconds,  the  most  intense  and  violent  smarting  commenced  in  the  part,  increas- 
ing to  such  a  degree  that  it  was  perfectly  insufferable,  and  we  were  instantly 
compelled  to  apply  active  cold  douching  to  the  parts.  The  pain  was  excrucia- 
ting ;  the  cuticle  was  uplifted,  and  the  surrounding  parts  deeply  reddened. 
Some  drops  which  escaped  from  the  tube,  lighting  on  the  forehead  of  one  of  us, 
caused  most  violent  pain.  The  smarting  continued  severe  afterwards,  and  the 
parts  assumed  the  appearance  of  urticaria.  The  pain  was  of  a  stinging  charac- 
ter, intense  and  prolonged  like  that  of  nettles.  This  was  due  evidently  to  the 
presence  of  acetic  acid,  which  produces  symptoms  quite  analogous  to  its  homo- 
logue,  formic  acid,  an  irritating  ingredient  in  the  glands  at  the  base  of  the  hairs 
in  various  species  of  stinging  urticas.  Chloroform  assists  the  action  of  the  acetic 
acid,  severe  enough  in  itself,  by  favouring  its  absorption  ;  and  we  know  that  a 
solution  of  extract  of  belladonna  in  chloroform  acts  with  tenfold  greater  rapidity 
than  an  ordinary  one.  On  the  whole,  then,  we  have  no  reason  to  be  pleased  with 
chloracetization.  In  the  course  of  the  white  mark  produced  no  pain  was  felt ; 
this  white  mark  differs  from  the  white  form  of  inflammation  (due  to  capillary 
paralysis),  in  being  caused  by  the  raised  cuticle.  When  deep  pressure  was 
made,  acute  pain  was  felt.  We  cannot  conceive  it  possible  for  the  mixture  to 
be  tolerated  for  five  minutes  on  any  part,  as  M.  Fournie  directs  ;  our  mutilated 
arms  still  bear  testimony  to  its  severity. 

"  Generalizations. — As  to  the  physiological  actions  of  these  various  articles, 
we  are  inclined  to  the  belief  that  they  do  not  produce  their  effects  till  an  action, 
amounting  to  one  of  revulsion  or  counter-irritation  is  brought  about ;  or  in  other 
words,  that  their  anaesthetic  effects  are  due,  and  contemporaneous  in  a  measure, 
with  a  counter-irritative  action,  since  a  varying  amount  of  irritation  in  all  cases 
precedes  the  anaesthesia.  We  mean  by  counter-irritation  the  production  upon 
the  surface  of  a  powerful  impression,  which  seems  to  be  capable  of  arresting  and 
diverting,  as  it  were,  the  attention  of  the  system,  and  thus  for  a  time  checking 
or  relieving  a  morbid  process. 

"  Also,  in  the  case  of  the  human  subject,  we  believe  the  local  application  of 
chloroform  in  vapour  to  possess  the  feeblest  anaesthetic  powers.  In  the  form 
of  liquid  the  effects,  though  transient,  are  much  more  strongly  marked.  The 
same  remarks  apply  also  to  the  liquor  ammoniae,  excepting  that  the  results  ob- 
tained from  its  vapour  were  negative." 


188 


Progress  of  the  Medical  Sciences. 


[Jan. 


The  experiments  with  ice,  according  to  the  plan  of  Dr.  J.  Arnott,  were  very 
satisfactory  ;  and  they7 say  '"it  becomes  a  question  whether  employment  should 
not  be  more  frequently  made  of  freezing  mixtures,  prior  to  superficial  operations 
in  surgery.  Of  course  it  can  only  be  expected  to  act  in  superficial  cases.  In 
private  practice  it  is  especially  a  desideratum  to  abrogate  pain,  even  in  the 
minor  operations ;  and  in  many  of  these  the  employment  of  chloroform  by  in- 
halation is  hardly  called  for,  or  indeed  warranted,  since  we  find  that  statistics 
show  a  greater  mortality  to  occur  from  the  use  of  chloroform  under  these  cir- 
cumstances. We  may  here  instance  some  operations  which  might  be  painlessly 
performed  by  this  method: —  , 

"1.  The  operation  for  onyxis  ;  the  toe  being  surrounded  by  the  mixture  till 
anaesthesia  be  produced. 

"  2.  The  removal  of  small  superficial  tumours.  This  division  is  a  very  com- 
prehensive one,  embracing  the  removal  of  malignant,  cystic,  benignant,  and  other 
growths. 

"  3.  The  opening  of  abscesses  ;  both  acute  and  chronic  when  superficial ;  in- 
cluding anthrax  and  furunculi. 

"  4.  The  operation  for  paraphymosis. 

"  5.  The  operation  for  femoral  hernia;  it  being  a  common  practice  to  apply 
ice  locally  to  facilitate  the  taxis. 

"  In  such  cases  we  consider  ice  to  be  without  doubt  the  most  valuable  form 
of  local  anesthetic,  from  its  admitting  of  simple  application  combined  with  the 
most  satisfactory  results." 

7.  Phlorydzine. — This  neutral  principle,  which  exists  in  considerable  quan- 
tities in  the  bark  of  the  root  of  the  apple,  plum,  and  cherry  tree,  is  recommended 
[Dublin  Quarterly  Journ.  Med.  Science,  Aug.  1'862)  by  Dr.  De  Ricci  as  being 
tolerated  where  neither  quinine  nor  salicine,  nor  bark,  can  be  administered  with- 
out bringing  on  serious  nervous  excitement.  The  cases  in  which  he  has  em- 
ployed this  article  with  most  success  are  those  of  atonic  dyspepsia  in  delicate 
females.  He  has  also  found  it  extremely  well  adapted  to  the  treatment  of  young 
delicate  children,  or  when  recovering  from  hooping  cough,  infantile  fever,  etc-. 
He  has  given  it  in  these  cases  combined  with  syrnp  of  phosphate  of  iron  and 
manganese,  and  with  syrup  of  iodide  of  iron.  He  gives  it  in  doses  of  five  grains 
three  or  four  times  a  day  for  adults,  and  proportionally  smaller  ones  for  children. 

He  recommends  a  trial  of  this  remedy  "in  every  adult  case  where  quinia  is 
not  easily  tolerated,  as  also  in  every  case  where  young  children  require  a  tonic 
treatment  either  in  consequence  of  constitutional  debility,  or  from  the  debilitat- 
ing effects  of  some  previous  illness ;  it  is  much  more  easily  taken  than  either 
bark,  quinia,  or  salicine,  the  bitter  being  of  an  agreeable  kind,  and  changing, 
as  I  said  above,  into  a  sweetish  taste,  with  the  flavour  of  apples.  I  have  never 
known  it  to  disagree,  even  in  large  doses  of  10  grains  three  or  four  times  a  day; 
and  I  have,  in  very  many  instances,  found  it  of  great  use  where  other  tonic  sub- 
stances, could  not  be  taken. 

"  In  prescribing  phlorydzine  it  must  be  borne  in  mind  that  it  is  almost  insolu- 
ble in  cold  water;  but  the  addition  of  a  very  small  quantity  of  ammonia  instantly 
dissolves  it ;  thus,  by  adding  to  an  eight  ounce  mixture,  containing  a  drachm  of 
phlorydzine,  a  few  drachms  of  aromatic  spirit  of  ammonia,  the  fluid,  which  pre- 
viously was  milky,  becomes  perfectly  clear;  and  the  addition  of  the  aromatic 
spirit  rather  improves  the  mixture  than  otherwise. 

"  If  a  small  quantity  of  phlorydze'in  be  previously  added  to  the  water  its  solv- 
ing power  is  increased,  and  the  mixture  will  be  of  a  beautiful  blue  colour,  but  it 
will  not  dissolve  as  much  phlorydzine  as  when  aromatic  spirit  of  ammonia  is 
employed." 

8.  Carbazotate  of  Iron. — Mr.  H.  N.  Draper  gives  (Dublin  lilfed.  Press,  Dec. 
3,  18G2)  an  interesting  account  of  this  new  preparation  of  iron.  The  following 
are  the  more  important  points. 

The  mode  of  preparing  it  is  as  follows:  Crystals  of  pure  carbazotic  acid  are 
digested  with  an  excess  of  recently  precipitated  sesquioxidc  of  iron  and  water 


1863.] 


Materia  Medica  and  Pharmacy. 


189 


at  a  gentle  heat  until  the  acid  has  disappeared.  The  whole  is  then  transferred 
to  a  paper  filter,  and  when  the  deep  yellow  solution  of  carbazotate  has  passed 
through,  the  residue  on  the  filter  is  to  be  washed  with  hot  water  until  the  fil- 
trate becomes  colourless  or  nearly  so.  The  washings  being  added  to  the  original 
solution,  the  whole  is  evaporated  to  dryness  at  a  temperature  not  exceeding 
212°. 

Physical  Characters. — Thus  prepared,  carbazotate  of  iron  presents  the  ap- 
pearance of  a  reddish  brown,  amorphous  mass,  which,  when  reduced  to  powder, 
becomes  lighter  in  colour.  Its  taste  is  astringent  and  intensely  and  persistently 
bitter. 

The  chemical  constitution  of  the  salt,  Mr.  D.  thinks,  is  three  equivalents  of 
carbazotic  acid  (C12  N?  H3  0I4)  united  to  one  of  sesqnioxicle  of  iron. 

'•Physiological  Action  and  Therapeutic  Use. — Carbazotic  acid  and  its  salts 
appear  to  possess  very  decided  tonic  and  antiperiodic  properties,  and  will  most 
probably  prove  on  more  extended  trial  valuable  and  economical  substitutes  for 
quinine.  In  large  doses  the  acid  is  poisonous  ;  according  to  Taylor,1  ten  grains 
have  sufficed  to  kill  a  dog  in  less  than  two  hours. 

"In  the  hands  of  Drs.  Calvert  and  Moffat.2  the  carbazotate  of  iron  has  proved 
very  successful  in  the  cure  of  cephalalgia;  the  same  authors  have  also  employed 
with  good  effect  the  ammonia  salt  in  the  treatment  of  anaemia,  intermittent  fever, 
and  hypochondriasis,  and  combined  with  opium  and  gallic  acid  in  obstinate 
diarrhoea.  They  observe  that  while  the  acid  itself  is  liable  to  produce  cramps, 
its  compounds  with  bases  are  free  from  this  objection.  The  dose  of  the  salts 
employed  by  these  experimentalists  was  from  .05  to  .10  gramme  (|  to  1-]-  grain) 
per  diem. 

"More  recently,  Mr.  Alfred  Aspland,3  of  the  Ashton  Eoyal  Infirmary,  has,  at 
the  request  of  Dr.  Calvert,  tried  carbazotic  acid  and  its  salts  on  a  more  exten- 
sive scale,  and  with  a  success  which  should  encourage  further  experiment.  Mr. 
Aspland  treated  forty  severe  cases  of  ague,  giving  the  acid  in  doses  of  a  grain 
three  times  a  day,  gradually  increased  to  four  grains  at  each  dose.  Some  of  the 
patients  were  relieved  in  forty-eight  hours,  while  in  two  cases  the  treatment  had 
to  be  continued  for  nine  weeks.  Mr.  Aspland  has  also  employed  the  acid  with 
good  results  in  diabetes,  in  anaemia  and  prostration  from  loss  of  blood  in  infan- 
tile marasmus,  in  rickets,  and  as  a  tonic  in  cases  of  debility,  and  where  quinine 
is  usually  given  ;  also  in  dyspepsia  and  hypochondriasis.  He  states  himself  as 
unable  to  decide  whether  the  salts  of  carbazotic  acid  or  the  acid  itself  act  better, 
and  does  not  allude  to  any  inconvenience  resulting  from  the  use  of  either  beyond 
the  peculiar  colouration  of  the  skin  always  attending  the  continued  use  of  this 
remedy. 

"The  iron  salt  will  probably  be  found  from  its  ready  solubility  one  of  the  best 
forms  of  administering  carbazotic  acid,  and  especially  suitable  as  a  substitute 
for  the  combination  of  quinine  with  ferric  salts.  It  should,  on  account  of  its 
intensely  bitter  taste,  be  administered  in  the  form  of  pills. 

"A  most  remarkable  result  produced  by  the  continued  exhibition  of  t^his  acid 
and  its  salts  is  that  the  skin  and  conjunctiva?  of  the  eyes  become  dyed  of  a  deep 
yellow  hue,  and  the  urine  acquires  an  orange  colour.  This  effect  is,  according 
to  Drs.  Calvert  and  Moffat,  generally  brought  about  in  a  time  varying  from  two 
to  sixteen  days  after  the  commencement  of  the  treatment,  or  when  about  fifteen 
grains  of  the  acid  have  been  taken,  and  they  are  inclined  to  attribute  the  failure 
of  Braconnot  in  producing  this  colouration,  to  the  fact  that  he  employed  the 
potash  salt,  which  is  almost  insoluble.  Mr.  Aspland,  whose  experiments  have 
been  cited  above,  finds  that  the  skin  becomes  most  easily  tinged  in  robust  sub1 
jects,  and  more  in  adults  than  in  children.  The  urine,  on  the  other  hand,  is  more 
coloured  in  these  cases.  The  skin  in  the  best  dyed  cases  clears  in  two  or  three 
weeks  after  the  remedy  has  been  discontinued. 

"Dose. — From  half  a  grain  to  two  grains,  gradually  increased." 


1  On  Poisons,  p.  793. 

2  Pharm.  Journ.,  vol.  xvi.  p.  167. 

3  Med.  Times  and  Gazette,  vol.  ii.,  1862,  p.  289. 


190 


Progress  of  the  Medical  Sciences. 


[Jan. 


9.  Iodized  Coffee  of  Hutet. — The  basis  of  the  new  iodic  preparation  is  roasted 
coffee,  a  substance  in  daily  use  as  an  aliment,  and  with  most  persons  a  favourite, 
with  some  of  the  principles  of  which  iodine  combines  in  rather  a  considerable 
proportion.  To  attain  the  desired  object,  it  suffices  to  mix  the  requisite  quan- 
tity of  iodine  with  a  sufficiency  of  the  watery  infusion  of  coffee.  The  taste  of 
the  product  does  not  reveal  the  presence  of  the  new  body.  This,  however,  is 
easily  detected  by  chemical  reagents,  when  it  is  acted  on  as  is  directed  for  the 
examination  of  iodine  in  combination :  for  when  tested  with  starch  alone,  there 
is  no  indication  of  it,  it  being  necessary  to  treat  the  coffee  previously  with  chlo- 
rine. The  iodized  coffee,  which  contains  five  centigrammes  to  every  spoonful, 
a  very  large  proportion,  has  neither  colour,  taste,  nor  smell  different  from  ordi- 
nary coffee.  The  use  of  this  coffee  taken  in  doses  of  one  or  two  spoonfuls  a  day. 
for  several  days  in  succession,  did  not  produce  any  intolerance  (stanchezza)  of 
the  stomach :  a  certain  quantity  of  the  iodine  was  absorbed,  and  its  presence 
was  recognizable  in  the  urine  of  the  persons  who  used  it. 

The  employment  of  this  iodized  coffee  can  scarcely  fail  to  answer  its  intention, 
it  being  possible  to  regulate  the  dose  according  to  the  wish  of  the  physician. 
It  may  be  taken  with  sugared  water,  or  better  with  milk,  in  which  case  it  be- 
comes an  integrant  part  of  the  alimentation. — Dublin  Med.  Press,  from  Annali 
di  Chimica  Maggio. 

10.  Syrup  of  Carbonate  of  Iron. — Mr.  H.  N.  Draper  gives  (Dublin  Med. 
Press,  Dec.  3,  1862)  the  following  formula  for  the  preparation  of  this,  which  he 
considers  a  great  improvement  upon  the  usual  form. 

"  Carbonate  of  iron  readily  dissolves  in  simple  syrup,  and  as  the  sugar  exer- 
cises a  completely  preservative  influence  upon  the  salt,  this  is  one  of  the  best 
forms  in  which  it  can  be  exhibited : — 

Protosulphate  of  iron        ...       2  ounces. 

Carbonate  of  soda  in  crystals     .       .       2|-  " 

Water  2  pints. 

Sugar  4  ounces. 

"  Dissolve  the  sulphate  of  iron  and  half  the  sugar  in  one  pint,  and  the  car- 
bonate of  soda  and  the  remainder  of  the  sugar  in  the  other  pint  of  water,  mix 
the  solutions,  allow  the  precipitate  to  subside,  and  decant  the  supernatant  fluid. 
Then  rapidly  wash  the  precipitate  by  decantation,  using  for  the  washing  the 
whole  of  the  following  solution,  but  dividing  it  between  two  operations  : — 

Sugar"  5  ounces. 

Water  20  " 

"Next  digest  the  washed  precipitate  in  a  sufficient  quantity  of  sugar  solution 
of  like  strength,  agitating  it  repeatedly  during  some  days.  When  it  has  all  dis- 
solved add — 

Sugar  38-i-  ounces. 

Water  19  fluidounces. 

"Boil  to  a  specific  gravity  of  1.262  (at  boiling  point)  and  flavour  with  tinc- 
ture of  lemon  or  orange  peel.    This  syrup 'contains  about  ten  per  cent,  of  car- 
bonate of  iron,  is  nearly  colourless,  and  without  unpleasant  taste. 
"  Dose. — One  fluidrachm." 

11.  The  Permanent  Voltaic  Current  as  a  Therapeutic  Agent. — Dr.  Hiffel- 
sheim  has  published  a  work  ("Le  courant  Voltaique  continue  permanent,  #"c") 
which  contains  an  account  of  his  important  researches  into  the  effects  of  "dy- 
namic" electricity  upon  the  body.  The  following  are  the  most  important  con- 
clusions: 1.  It  is  not  desirable,  except  for  the  purpose  of  cauterization,  to 
employ  any  voltaic  combination  of  which  the  metallic  elements  present  large 
surfaces,  for  such  an  apparatus  produces  a  current  too  strong  and  disorganizing. 

*  The  surface  of  the  zinc  element  should  not  be  so  large  as  eight-tenths  of  a  square 
inch,  at  least  with  any  more  powerful  exciting  liquid  than  pure  water;  but  the 
number  of  elements  of  the  pile  must  be  increased,  in  order  to  overcome  the 
resistance  of  the  tissues.  2.  It  is  desirable  that  the  passage  of  the  current 
should  be  as  little  felt  by  the  shin  as  possible.  M.  Hiffelsheim  recommends  that 
the  conducting  plates  which  are  applied  to  the  surface  of  the  body  should  be 


/ 


1863.] 


Materia  Medica  and  Pharmacy. 


191 


gilded,  and  that  they  should  not  be  kept  moist  as  was  formerly  recommended. 
3.  The  current,  imperceptible  by  the  skin,  may  be  appreciated  by  the  interpo- 
sition of  a  voltameter,  in  the  course  of  the  circuit ;  and  the  author  prefers  for 
this  purpose  an  apparatus  for  the  decomposition  of  water.  The  amount  of  vol- 
taic action  may  be  computed,  either  by  estimating  the  quantity  of  hydrogen 
produced,  or  the  quantity  of  water  which  has  disappeared,  in  the  twenty-four 
hours.  A  current,  thus  carefully  graduated,  may  be  continuously  applied  during 
the  greater  part  of  each  twenty-four  hours,  and  its  action  in  this  respect  is  much 
more  efficacious  than  that  of  ordinary  "continuous"  currents,  which  can  only 
be  applied  for  a  short  time. — London  Med.  Rev.,  Oct.  1862. 

12.  Electro-galvanism  or  Galvanic  Electricity. — Dr.  W.  H.  Sandham,  of 
Cork,  extols  (Dublin  Med.  Press,  November  12,  1862)  the  therapeutic  powers 
of  galvanic  electricity.  He  says:  "From  my  experience  of  electricity,  I  have 
come  to  the  following  conclusions  :  1st.  Whenever,  in  the  treatment  Of  disease, 
an  antispasmodic  or  calmative,  a  soporific,  stimulant  or  tonic  is  indicated,  gal- 
vanic electricity  ought  not  to  be  dispensed  with.  2d.  It  is  valuable  as  a  means 
of  diagnosing  disease.  3d.  It  is  a  very  useful  agent  to  put  the  system  in  the 
best  possible  state  to  receive  and  be  acted  upon  by  medicine.  4th.  No  matter 
whether  the  case  suited  its  application  or  not,  in  no  instance  did  I  see  the 
slightest  unpleasant  symptom  or  derangement,  that  could  not  be  at  once  reme- 
died, follow  its  administration. 

"I  have  used  it  in  colic,  neuralgia,  sciatica,  delirium  tremens  [by  the  by  a 
disease  for  which  I  have  not  yet  read  or  heard  of  its  being  used  or  suggested 
by  any  one  else),  fever,  or  at  least  cases  with  every  symptom  of  fever  present, 
dentition,  hooping-cough,  convulsions,  lumbago,  burns  (to  relieve  the  pain), 
headache,  toothache,  gout,  cerebral  disturbance,  the  latter  so  interesting  and 
inexplicable,  and  in  all  with  decided  benefit.  The  length  of  time  for  which  a 
patient  suffered  seemed  of  no  serious  moment  when  it  exactly  suited  the  case, 
whether  the  malady  was  recent  or  of  long  standing,  it  indicated  more  or  less 
control  in  every  case  in  which  I  tried  it.  In  fine,  could  I  but  succeed  in  making 
permanent  the  good  results  that  in  almost  every  case  I  have  for  a  time  pro- 
duced, I  would  look  upon  galvanic  electricity  as  nothing  short  of  a  wonderf  ul 
remedy."    *  * 

"  In  my  humble  experience,  electricity  in  its  vibratory,  intermittent,  or  shock 
form,  is  not  near  so  generally  useful,  except  in  local  paralysis,  as  what  Dr. 
Golding  Bird  calls  the  single  current,  but  what  is  better  described  as  '  the  con- 
tinuous current  without  shock.1  This,  in  my  mind,  is  the  great  tonic,  calmative, 
antispasmodic,  and  antineuralgic  electric  current,  whose  beneficial  results  are 
apparent,  in  many  cases,  in  a  few  moments,  and  does  not,  as  is  the  case  with 
Dr.  Neligan's  shock  current,  require  a  long  time  for  the  development  of  its 
effects,  as  my  cases  will  incontestably  prove.  Dr.  Golding  Bird,  Physician  to, 
and  Lecturer  on  Therapeutics  at,  Guy's  Hospital  [vide  Lancet,  vol.  ii.  xvii. 
1851),  says:  'Shocks  are  not  required  to  develop  physiological  phenomena  or 
therapeutic  effects,  as  the  laborious  researches  of  Dr.  Marshall  Hall  have  long 
since  proved,  and  it  is  only  to  the  mild  continuous  voltaic  current  that  we  must 
look  for  a  vast  development  of  therapeutical  influence.' 

"I  both  use  and  look  upon  electricity,  in  whatever  form  it  may  be  adminis- 
tered, as  an  auxiliary — but  in  my  mind  a  very  powerful  auxiliary — to -the  other 
modes  of  treatment.  Let  it  not  for  one  moment  be  supposed  that  I  look  upon 
electricity  as  a  universal  remedy.  No.  I  treat  my  cases  medico-galvanically, 
invariably  giving  the  medicines  which  in  my  opinion  are  indicated  in  each  case. 
Having  never  read  or  heard  of  galvanic  electricity  being  recommended  or  sug- 
gested as  a  remedy  for  the  cure  of  dipsomania  or  delirium  tremens,  I  beg  to 
draw  particular  attention  to  the  four  first  cases ;  they  were  treated  by  'the  mild 
continuous  current  without  shock,'  as  administered  by  the  aid  of  'Pulverma- 
cher's  apparatus ;'  I  do  so  in  the  hope  that  other  gentlemen  may,  in  a  short 
time,  give  us  their  experience,  and  thereby  still  further  establish  or  set  aside 
the  use  of  galvanism  in  this  dread  disease.  You  may  rely  on  the  faithfulness 
of  my  report;  indeed,  you  have  (Case  3d)  reported  and  certified  in  the  words  of 
one  of  my  patients,  and  as  it  is  the  history  of  the  only  case  treated  by  me  with- 


192 


Progress  of  the  Medical  Sciences. 


[Jan. 


out  medicine  of  any  land,  I  refrain  from  recording  it  in  any  other  form  than 
that  of  the  certificate  itself.  It  is  true  to  the  letter,  and  describes  accurately 
all  that  I  did  for  him. 

"The  'wet  brain'  and  the  'congested  brain,'  induced  by  alcoholic  poisoning, 
are  generally  treated  by  large  doses  of  opium,  with  or  without  depletion,  or,  as 
advocated  by  some,  on  the  expectant  plan.  We  all  know  how  near  to  death 
perseverance  in  large  doses  of  the  former  oftentimes  bring  the  patient.  Now,  if 
galvanism  would  enable  us  to  cure  delirium  tremens,  by  giving  with  it  smaller 
and  consequently  safer  doses  of  opium,  it  would  be  a  desideratum ;  but  T  hazard 
the  opinion  that  opium  and  galvanism  act  in  antagonism  to  each  other,  and 
would  rather,  therefore,  use  the  one  without  the  other.  Dipsomania  or  delirium 
tremens  is  a  state  of  things  induced  by  over  excitement  or  over  stimulation  of 
the  nervous  system." 


MEDICAL  PATHOLOGY  AND  THERAPEUTICS,  AND  PRACTICAL 

MEDICINE. 

13.  Further  Observations  on  Typhus  and  Typhoid  Fevers,  as  seen  in  Dub- 
lin, especially  the  united  form  which  they  assumed  during  the  first  half  of  the 
year  1862. — In  1860,  Mr.  Henry  Kennedy  read  before  the  Royal  Medical  and 
Chirurgical  Society  a  paper  (see  No.  of  this  Journal  for  July,  1860,  pp.  237 — 9), 
the  object  of  which  was  to  show  that  typhus  and  typhoid  fevers  were  the  result 
of  a  common  poison.  In  a  late  No.  (August,  1862)  of  the  Dublin  Quarterly 
Journal  of  Medical  Science,  he  has  published  the  results  of  his  additional  expe- 
rience ;  and  gives  the  details  of  forty  cases  illustrative  of  the  types  of  fever  pre- 
vailing in  Dublin  the  last  two  and  some  former  years.  These  cases  present 
examples  "of  typhus  in  both  young  and  old; — of  typhus  without  spots; — of 
typhoid  with  none,  with  one  or  two,  or  with  an  extensive  crop  of  them ; — of 
typhus  with  the  brain  wonderfully  free ; — cases  of  typhoid,  but  more  numerous, 
the  same ; — of  both  typhus  and  typhoid  in  which  the  state  of  the  tongue  and 
parts  about  were  identical  from  sordes ; — many  cases  of  either  type  with  the 
chest  not  engaged  at  all,  or  so  slightly  as  not  to  call  for  treatment : — instances 
of  both  types  with  and  without  tympany ; — cases  of  either  kind  entirely  free 
from  hemorrhage;  a  freedom  remarkable  when  compared  with  former  years; — 
and  lastly,  the  modified  types  of  fever  which  the  present  year  has  disclosed." 

The  conclusion,  Dr.  K.  says,  "  at  which,  after  the  fullest  consideration  of  this 
question,  I  have  arrived  is  the  same  as  that  of  two  years  since ;  but  with  still 
stronger  convictions  on  the  point.  /  believe  that  the  two  fevers  known  as  typhus 
and  typhoid  are  the  result  of  a  single  poison;  and  that  no  other  hypothesis  can 
explain  so  well  all  the  difficulties  of  the  case.  I  consider,  further,  that  those 
who  hold  for  a  plurality  of  poisons,  are  bound  to  explain  the  facts  already  given 
in  this  paper.  They  should  tell  us  why  the  symptoms  of  those  two  affections 
so  often  run  the  one  into  the  other;  why  the  same  type  of  fever,  whether  typhus 
or  typhoid,  presents  such  marked  contrasts  ;  why  typhoid  may  assume  the  cha- 
racters of  putrid,  ataxic,  or  inflammatory  fevers  ;  febricula,  meningitis,  &c,  and 
still  be  typhoid  all  the  time ;  and  this,  be  it  observed,  is  described  by  those  who 
believe  in  the  two  distinct  poisons.  They  will  also  have  to  answer  the  argument 
taken  from  analogy,  and  tell  us  if  scarlatina  affords  the  most  marked  contrasts, 
why  fever  should  not  do  the  same;  also  how  it  has  happened  that  symptoms 
which  one  writer  considers  essential  to  the  natural  history  of  typhoid,  are  ignored 
or  made  little  of  by  another.  And,  in  the  last  place,  an  explanation  must  be 
given  of  what  has  occurred  in  Dublin  this  year — that  is  the  union  of  typhus  and 
typhoid  in  the  same  subject.  Now  one  and  all  these  points  may  be  satisfactorily 
explained  on  the  idea  of  the  existence  of  but  one  poison.  I  confess,  however, 
it  appears  to  me  impossible  to  explain  them  on  the  theory  of  two.  But,  if  we 
admit  two,  why  not  more;  for  assuredly  there  are  other  types  of  .fever  just  as 
distinct  as  typhus  is  from  typhoid.    And  this  leads  me  to  notice  the  third  type 


1863.]  Medical  Pathology  and  Therapeutics. 


193 


which  prevailed  this  year  in  Dublin,  and  particularly  amongst  the  middle  ranks  ; 
I  mean  gastric  fever.  I  hold  that  it  is  essential  it  should  be  distinguished  from 
typhoid  fever,  with  which  it  has  the  nearest  connection ;  were  it  for  no  other 
reason  than  that  its  treatment  is  very  different.  Several  cases  of  it  have  been 
already  detailed ;  but,  except  to  notice  it  as  a  special  type  of  fever,  I  am  not 
about  to  speak  of  it  further  here.  It  was,  I  believe,  to  this  type  of  fever  that 
the  cases  given,  which  might  fairly  be  called  anomalous,  are  chiefly  to  be  re- 
ferred." 

14.  Treatment  of  Typhoid  Type  of  Fever. — Dr.  H.  Kennedy,  of  Dublin,  ex- 
presses the  opinion  [Dublin  Quarterly  Journ.  Med.  Science,  August,  1862)  that 
the  treatment  adopted  by  some  is  not  of  the  specific  kind  which  this  affection 
appears  to  him  to  require.  "  We  know,"  he  says,  "  that  of  late  years  anything 
of  what  would  be  called  active  treatment  has  been  most  materially  modified,  if 
not  quite  given  up.  Thus  in  Bartlett's  work,  which  appeared  in  1847,,  the  mea- 
sures recommended  included  the  regular  antiphlogistic  treatment ;  whilst  five 
years  later  Flint  speaks  of  much  milder  measures  being  adopted.  The  late  Dr. 
Todd,  of  London,  we  know,  strenuously  recommended  the  stimulant  plan  ;  which, 
it  must  be  allowed,  he  carried  as  far  as  any  discretion  would  justify;  and  in  a 
published  lecture  of  the  present  year,  Dr.  Warde,  of  the  Dreadnought  Hospital, 
London,  has  advocated  the  leaving  the  disease  very  much  to  itself.  Now  I  men- 
tion these  plans,  not  to  criticise  them  ;  but  to  state  that  each,  in  its  turn,  will 
be  found  useful ;  and  that  no  physician  who  has  fever  to  treat  on  the  large  scale, 
will  bind  himself  to  one  or  the  other.  Every  single  instance  must  be  treated 
by  itself,  and  symptoms  must  be  met  as  they  rise.  If  this  be  done,  I  believe 
the  typhoid  type  to  be  the  most  amenable  of  the  many  forms  of  fevers,  provided 
it  be  seen  in  an  early  stage  of  the  disease.  Speaking  of  it  as  I  have  generally 
seen  it,  I  would  say  it  is  not  a  fever  to  be  left  to  itself;  and  several  of  the  cases 
which  have  been  detailed  prove  this  ;  for  there  was  no  amendment  till  treatment 
was  put  in  force  :  on  the  contrary,  some  of  them  were  going  from  bad  to  worse. 
When  then  the  case  calls  for  it,  and  this  is  to  be  learned  from  the  local,  as  well 
as  the  general  symptoms,  I  never  hesitate  to  have  leeches  applied  over  the  right 
iliac  region,  followed  by  a  poultice  ;  taking  care  the  bites  do  not  bleed  too  long. 
A  more  common  plan,  however,  is  the  application  of  a  blister  to  the  same  part: 
nor  can  I  doubt  the  great  value  of  such  means,  and  believe  it  is  not  as  gene- 
rally used  as  it  might  be.  The  blister  may  be  repeated  with  the  best  results  ; 
nor  should  we  ever  forget  that  the  local  disease  with  which  we  have  to  contend 
is  very  apt  to  be  slow  in  yielding ;  that  a  relapse  may  readily  occur,  and  when 
this  happens  the  disease  is  rendered  very  much  more  grave  than  it  was.  Our 
object,  in  truth,  is  to  prevent  ulceration ;  for  if  this  once  occur  the  chances  of 
recovery  are  materially  lessened.  I  state  this  because  a  recent  writer  speaks  of 
the  disease  as  if  ulceration  must  necessarily  take  place.  I  believe  this  is  an 
erroneous  way  of  considering  the  matter ;  and  that  we  can,  by  treatment,  anti- 
cipate, and  so  prevent  it.  '  Obsta  principiis'  is  all  important  here,  and  a  prin- 
ciple never  to  be  forgotten. 

"Of  the  internal  treatment  I  have  had  no  occasion  to  change  from  what  was 
spoken  of  in  the  former  paper.  As  an  astringent  I  find  the  dilute  sulphuric 
acid,  in  the  proportion  of  one  to  three  drachms  to  the  eight  ounce  mixture,  by 
much  the  best  remedy.  No  other  of  the  class  of  astringents  seems  to  me  to  act 
at  all  so  satisfactorily ;  and  it  can  be  modified,  with  the  greatest  nicety,  to  the 
demands  of  each  particular  case.  I  have  often  seen  medicines,  such  as  chalk, 
gallic  acid,  lead  and  opium,  unavailingly  used;  and  then  from  the  moment  this 
acid  was  given  the  patient  began  to  amend.  But  it  is  not  to  be  used  without 
discretion ;  for  it  may  check  the  diarrhoea  too  suddenly,  and  the  chest  or  brain 
may  so  become  engaged :  hence,  it  is  best  to  begin  with  a  moderate  dose,  and 
increase  if  the  necessity  arise.  The  rule  is  that  the  diarrhoea  is  to  be  gradually 
lessened  ;  not  suddenly  stopped.  In  mild  cases  I  find  the  acid  infusion  of  roses 
a  very  suitable  medicine;  and,  when  there  is  pain,  from  two  to  six  drops  of 
laudanum,  in  each  dose  of  the  mixture,  commonly  answers  well.  The  sulphuric 
acid,  I  need  scarcely  add,  is  the  favourite  remedy  with  Huss.  When  there  are 
No.  LXXXIX.— Jan.  1863.  13 


194 


Progress  of  the  Medical  Sciences.  [Jan. 


signs  of  irritation  in  the  colon,  and  more  especially  when  there  is  tenesmus,  an' 
anodyne  enema  acts  like  a  charm. 

"  Dr.  Warde,  to  whom  I  have  before  alluded,  speaks  of  salines  as  being  suited 
to  the  treatment  of  fever  of  the  typhoid  type.  Such  may  answer  in  London ; 
but  with  us  in  Dublin  they  would  be  positively  injurious.  Their  effects  on  the 
healthy  frame  are  quite  too  powerful  to  suppose  that  they  would  not  act  equally 
so  on  the  frame  weakened  by  a  disease  like  fever ;  of  which  the  best  treatment 
now  avowedly  is,  what  may  be  called,  conservative.  To  the  class  of  salines  I 
would  add  the  carbonate  of  ammonia,  which  I  believe  to  be  too  indiscriminately 
used ;  and  which,  in  my  own  experience,  does  not  suit  the  type  of  fever  of  which 
I  am  speaking.  I  have  known  a  very  few  doses  of  it  bring  on  diarrhoea ;  not 
only  in  this  fever,  but  in  many  other  diseases ;  and,  if  my  memory  serve  me  right, 
I  have  seen  a  similar  remark  made  by  Sir  Benjamin  Brodie;  and  would  hence 
hold  out  a  warning  against  the  use  of  either  salines  or  alkalies  in  all  diseases  of 
a  lowering  type. 

"  There  is  a  class  of  cases  of  the  typhoid  fever  in  which,  without  any  inter- 
ference, the  diarrhoea  suddenly  ceases ;  whilst  the  chest,  or  it  may  be  the  brain, 
gets  as  suddenly  involved.  All  such  I  have  found  turn  out  most  critical,  and 
I  have  latterly  been  in  the  habit  of  keeping  up,  for  some  days,  a  discharge  from 
a  small  blister,  usually  put  on  the  chest.  In  this  way  I  think  I  have  seen  very 
beneficial  results  follow.  It  seemed  as  if  the  poison  were,  in  part  at  least,  got 
rid  of  by  the  system ;  and  all  went  smoothly  afterwards.  The  point,  I  believe, 
is  worth  bearing  in  mind,  and  so  is  mentioned. 

11  In  the  last  place  I  would  notice  a  point  which  was  also  spoken  of  on  a  former 
occasion.  Are  stimulants,  as  a  class,  used  too  indiscriminately?  I  think  they 
are.  It  seems  a  very  general  impression  that  if  .they  are  to  be  used,  it  matters 
little  of  what  kind  they  are :  hence,  brandy,  wine,  and  beef  tea,  are  constantly 
spoken  of  as  being  given  to  the  same  patient.  Now  I  do  not  deny  that  all  may 
be  required  at  the  same  time.  But  I  do  say  that  in  numerous  instances  judg- 
ment is  to  be  exercised;  for  most  assuredly  the  effects  are  not  the  same  ;  and 
when  their  different  composition  is  considered  this  need  not  excite  wonder. 
Thus,  if  we  compare  wine  and  beef  tea,  the  former,  contrary  to  what  might  at 
first  be  thought,  may  be  given  with  much  less  risk  than  the  latter;  and  I  am 
sure  I  have  seen  cases  where  secondary  inflammations — in  the  chest  amongst 
other  parts — have  been  lighted  up  by  want  of  attention  to  the  very  point  of 
which  I  speak.  Though  much  more  might  be  said  on  this  subject,  enough  has 
been  advanced  for  my  present  purpose. 

"  In  conclusion,  I  would  observe,  that  the  class  of  mixed  cases,  as  they  may 
be  well  called,  require  even  more  than  the  ordinary  amount  of  attention.  The 
fever  becomes  so  heavy  in  many  of  them  that  the  abdominal  symptoms  are  very 
apt  to  be  masked,  and  so  may  readily  be  overlooked.  In  such  cases,  too,  it  may 
be  requisite  to  direct  our  treatment  at  one  time  to  the  chest,  or  again,  to  the 
brain ;  and,  in  some  of  the  cases  given,  a  combined  treatment  had  to  be  adopted." 

15.  Epidemic  of  Typhus  in  Iceland. — Dr.  John  Hjaltelin  gives  (Ed.  Med. 
Journ.,  Sept.  1862)  a  very  interesting  account  of  a  dreadful  epidemic  of  typhus, 
which  began  in  the  northern  part  of  the  island  of  Iceland  during  the  winter  of 
1857-58,  and  was  thence  apparently  communicated  by  contagion  to  the  eastern, 
western,  and  southern  districts  of  the  country.  During  the  winter  of  1857,  about 
ninety  cases  of  this  fever  came  under  Dr.  H.'s  observation,  and  it  presented 
sometimes  the  character -of  exanthematous  typhus,  and  sometimes  of  typhoid  or 
"typhus  abdominalis ;"  but  although  the  sickness  abated  in  the  following  sum- 
mer, it  again  appeared  in  the  autumn  of  1858,  and  raged  during  the  whole 
winter  of  1859,  and  did  not  even  cease  in  the  summer  months  of  that  year,  but 
continued  its  ravages  through  all  the  seasons  of  1859  and  1860.  In  those  two 
years  no  less  than  900  cases  came  under  Dr.  H.'s  treatment,  out  of  a  popu- 
lation of  about  10,000  inhabitants,  although  of  this  number  there  were  many 
patients  that  he  had  no  time  to  register.  When  the  fever  broke  out  in  a  farm 
or  cottage,  it  generally  attacked  one  person  after  the  other,  until  most  of  the 
inmates  of  the  house  were  infected ;  and  it  very  often  happened  that  strangers 


1863.]         Medical  Pathology  and  Therapeutics.  195 


stopping  in  a  house  thus  infected,  contracted  the  disease.  It  was  evident,  there- 
fore, that  it  was  highly  contagious. 

In  the  beginning  of  1860,  the  same  fever  was  very  often  accompanied  by 
malignant  dysentery ;  and  at  this  time  also,  when  by  far  the  greater  number  of 
the  infected  were  suffering  from  typhoid  fever,  Asiatic  cholera  made  its  appear- 
ance, and  was  accompanied  by  rice-water  evacuations  and  cramps,  but  happily, 
it  was  only  sporadic,  and  did  not  spread  by  contagion.  During  the  last  winter, 
1860-61,  the  typhus  fever  was  decreasing,  although  it  still  displayed  its  former 
malignity,  and  was  attended,  especially  in  the  eastern  part  of  this  country,  by 
great  mortality.  In  some  parishes  of  this  part  of  Iceland,  one-tenth  of  the  in- 
habitants fell  victims  to  the  disease,  a  catastrophe  which  seems  attributable  to 
there  having  been  an  entire  deficiency  of  medical  men,  and  medical  aid.  The 
same  phenomenon  was  observed  in  many  other  parts  of  the  country,  affording 
a  strong  argument  against  those  who  are  of  opinion  that  medical  aid  has  very 
small  influence  on  the  mortality  of  malignant  fevers. 

In  the  last  winter  mentioned,  about  122  cases  of  typhus  and  typhoid  fever 
came  under  Dr.  H.'s  treatment,  and  although  the  disease  was  becoming  more 
and  more  sporadic,  it  still  preserved  the  same  characters  of  malignity  and  con- 
tagion as  it  had  shown  in  former  years.  In  the  beginning  of  the  spring,  cases 
of  malignant  cholera  seemed  to  gain  ground,  and  were  generally  more  common 
than  the  typhus  itself,  but  the  disease  did  not  spread,  and  was  limited  to  some 
fishermen's  huts. 

As  to  the  probable  causes  of  these  malignant  diseases,  Dr.  H.  states,  that  in 
the  years  1856-57,  an  epizootic — common  sheep  scab — visited  Iceland,  and  it 
was  determined  to  get  rid  of  this  epizootic  by  slaughtering  all  the  infected  sheep, 
which  was  done  in  spite  of  Dr.  H.'s  remonstrances  and  predictions  of  the  evils 
which  would  follow.  No  less  than  200,000  sheep,  many  of  them  quite  sound,  fell 
victims. 

Dr.  H.  had  foretold,  he  says,  "that  this  proceeding  would  most  likely  lead  to 
fearful  consequences,  especially  on  account  of  the  great  masses  of  meat  heaped 
together  in  the  small  storehouses  that  are  commonly  attached  to  the  Icelandic 
farm,  the  single  apartment  of  which  is  used  as  a  parlour,  dining-room,  and  bed- 
room. I  supposed — and  experience  showed  that  I  was  right — that  my  country- 
men's un cleanliness,  and  their  bad  method  of  salting  meat,  would  lead  to 
most  dangerous  consequences ;  and  that  so  protracted  a  deprivation  of  sheep- 
milk,  butter,  and  cheese,  might  not  only  be  attended  by  a  deficiency  of  healthy 
and  nourishing  diet,  but  also  give  rise  to  famine. 

"  The  sheep  killed  amounted  in  number  to  about  one-third  part  of  those  con- 
tained in  the  island,  and  were  intended  to  supply  twelve  months'  nourishment  to 
about  10,000  men.  So  convinced  was  I  of  the  injurious  consequences  of  this 
foolish  enterprise  that  I  wrote  to  the  Board  of  the  Sanitary  College  at  Copen- 
hagen, predicting  what  would  happen  if  the  sheriffs  of  this  country — who  were 
its  authors  and  executors — were  not  to  be  deterred  from  its  prosecution.  The 
Danish  government  upon  this  enjoined  them  to  desist;  the  order,  however, 
arrived  too  late,  the  slaughter  having  been  already  executed  during  the  autumn 
of  1857,  and  the  following  winter. 

"  Meantime,  my  predictions  were  realized.  People  coming  from  the  country 
where  large  stores  of  salt  provisions  existed  in  great  abundance,  informed  me 
that  the  odour  of  rotten  meat  was  in  many  houses  insupportable  ;  they  declared 
that  they  could  neither  stay  nor  sleep  in  them,  and  a  short  time  afterwards  I 
heard  that  typhus  and  typhoid  fever  had  broken  out  in  several  parishes  of  the 
north,  and  both  these  diseases  were  subsequently  extended  by  contagion  to  the 
southern  districts. 

"  During  the  winter  the  peasants  came  down  from  the  highland  districts  to  the 
fishing  places  near  Keykjavik,  and  the  surrounding  districts.  In  many  of  these 
persons  the  malady  already  existed  in  its  latent  form.  On  arrival,  they  sickened 
and  spread  the  fever  in  the  fisher  cabins,  which  were  the  more  susceptible  to  its 
influence,  as  they  had  been  overcrowded  during  the  winter  of  1858.  From  this 
time  the  disease  advanced  from  hut  to  hut,  until  the  majority  of  them  were  in- 
fected by  its  virulence ;  the  most  crowded  huts  were  of  course  infected  first  and 
most  severely;  but  by  and  by  the  better  houses  became  infected  also,  towards 


196 


Progress  of  the  Medical  Sciences. 


[Jan. 


the  end  of  the  winter  of  1858.  The  mercury  sank  to  4°  below  zero,  Fahrenheit, 
and  continued  there  for  several  weeks.  It  was  very  remarkable  to  see  how  the 
typhus  was  for  a  time  arrested  by  the  severe  cold,  but  re-excited  when  the  tem- 
perature grew  milder.  This  fresh  outbreak  continued  until  the  end  of  May,  at 
which  period  it  ceased  or  abated,  to  reappear  in  autumn." 

16.  Disinfecting  Treatment  of  Typhus  and  Typhoid  Fever. — Dr.  John 
H.taltelin  gives  the  following  as  the  indications  for  his  disinfecting  treatment 
of  typhus  and  typhoid  fever,  and  which  he  employed  with  advantage  in  the  ter- 
rible epidemic  which  prevailed  in  Iceland  from  1857  to  1860.    These  are : — 

"  1st.  To  prevent  overcrowding  in  the  farm-huts  and  cabins  as  far  as  possible, 
where  this  in  any  way  could  be  done. 

"  2d.  To  have  the  windows  thrown  open  as  often  as  the  season  would  allow 
it,  and  make  holes  for  ventilation  where  this  could  be  most  effectually  done  for 
purifying  the  air. 

"  3d.  To  destroy  every  offensive  odour  about  the  sick,  and  even  the  smell  of 
the  sickness  itself. 

"  4th.  To  introduce  cleanliness  in  every  re*spect. 

"  5th.  To  clean  the  bowels  of  the  patients  as  soon  as  possible  in  an  effective 
and  perfect  manner. 

li  6th.  To  destroy  instantly  the  odour  of  evacuations  from  the  patients. 

"  7th.  To  use  internally  disinfecting  medicines  in  a  bold  and  consequent 
manner. 

"  8th.  To  support  the  strength  .of  the  patients  by  easily  digestible  but  nourish- 
ing foods. 

The  first  indication  could  very  seldom  be  fulfilled,  but  it  was  done  whenever 
possible.  The  second  indication  was  for  the  most  part  tolerably  executed, 
especially  when  the  people  got  afraid  of  the  contagion,  and  therefore  dared  not 
shut  their  windows,-  but  followed  for  the  most  my  advice  in  opening  them. 

"  The  third  indication  was,  after  the  lapse  of  some  time,  when  the  people  had 
seen  the  good  effect  of  it,  boldly  executed ;  and  the  remedies  applied  to  this 
purpose  were  the  aforesaid  disinfecting  compounds,  viz.,  chlorine-gas,  Sir  Wil- 
liam Burnett's  chloride  of  zinc  solution,  iodoform,  and  charcoal. 

4'  The  fourth  indication  met  with  many  obstacles,  and  could  seldom,  on  account 
of  bad  habits  or  poverty,  be  executed  as  it  ought  to  have  been,  or  would  have 
been,  if  cleanliness  were  a  more  common  virtue  in  this  country. 

"  The  fifth  indication  was  fulfilled  by  administering  a  full  dose  of  calomel,  sul- 
phate of  magnesia,  or  sulphate  of  soda,  all  in  large  and  repeated  doses,  accord- 
ing to  age  and  other  circumstances.  The  calomel  was  generally  given  in  a  dose 
of  ten  to  twenty  grains  every  day,  or  every  second  day,  until  the  fetid  odour  of 
the  dejections  was  gone.  As  the  effect  of  this  treatment,  I  may  mention  the 
lessened  tenderness  in  the  right  iliac  region  and  in  the  whole  abdomen,  lowering 
of  the  pulse,  diminished  headache,  and  more  clear  consciousness  of  the  mind, 
when  from  the  beginning  there  had  been  stupor  or  coma.  In  some  cases  sulphate 
of  magnesia  was  given  in  a  dose  of  a  half  or  one  ounce,  until  I  was  pretty  sure  of 
the  bowels  being  well  cleaned,  and  all  bad  odour  of  the  evacuations  had  disap- 
peared. 

"  In  order  to  execute  the  sixth  indication,  sulphate  of  iron  was  generally  put 
into  the  water-closets  before  they  were  used ;  but,  in  some  cases,  chloride  of 
lime  was  used  for  the  same  purpose.  By  these  disinfecting  compounds  no  odour 
of  the  dejections  could  be  felt,  although  the  patients  had  very  large  and  noxious- 
smelling  evacuations.  I  think  that  every  one  who  knows  the  small  and  dirty 
Icelandic  huts  will  agree  with  me  that  this  is  a  quite  indispensable  proceeding 
to  purify  the  air,  where  many  patients  are  crowded  together  in  small  rooms. 
This  method  seldom  failed  to  produce  a  happy  effect  upon  the  patients.  The 
seventh  indication  was  executed  in  several  manners.  If  the  patients  were  sup- 
posed to  have  strong  and  healthy  respiratory  systems,  they  were  made  to  inhale 
iodoform  or  chlorine  gas  mixed  with  the  air.  The  former  remedy  was  most  fre- 
quently used,  and  the  good  effect  of  it  (according  to  my  experience)  is  undeni- 
able.   It  was  in  some  instances  given  internally,  dissolved  in  ether,  and  seemed 


/ 

I. 

1863.]  Medical  Pathology  and  Therapeutics.  197 

often  to  produce  a  well-marked  relief,  and  especially  it  was  observed  to  check 
coma  and  delirium.  The  chloride  of  lime  was  never  used  internally,  but  the 
patients  were  often  made  to  inhale  the  vapour  of  a  concentrated  solution  of 
chloride  of  lime,  which  was  managed  in  this  manner :  Linen  strips  were  dipped 
in  the  solution,  and  hung  up  to  dry  by  the  bedside,  which  caused  a  continuous 
chlorine  gas  exhalation  in  the  room.  By  patients  with  weak  and  irritable  lungs 
the  iodoform  was  always  preferred  to  the  chlorine  gas. 

"The  eighth  indication,  namely,  to  support  the  strength  of  the  patients,  was 
fulfilled  by  nourishing  food  and  decoction  of  bark  ;  and  this  was  sometimes  re- 
curred to  in  the  third  stage  of  the  fever,  in  order  to  prevent  death  from  exhaus- 
tion. It  seems  to  me  that  many  physicians  are  too  much  afraid  of  using  nour- 
ishing diet  in  typhus  fever,  forgetting  the  great  loss  of  nitrogenous  compounds 
which  this  sickness,  by  the  large  excretion  of  urea,  produces.  I  have  seen  many 
typhus  patients  in  this  country,  who,  as  soon  as  they  were  able,  took  very  nour- 
ishing food,  which  would  never  be  allowed  in  the  hospitals  of  Europe,  recover 
speedily;  and,  comparing  this  fact  with  the  languishing  and  protracted  recovery 
in  the  hospitals,  I  conclude  that  nourishing  food  in  the  latter  stages  of  this  fever 
is  quite  indispensable. 

"  As  to  the  result  of  my  treatment,  I  am  obliged  to  make  some  remarks,  and 
in  so  doing  it  is  necessary  to  mention  the  ravages  of  the  typhus  fever  in  our 
country  during  the  years  1859  and  1860.  In  the  northern  part  of  this  island, 
and  on  the  western  shores,  a  good  many  patients  fell  victims  to  it ;  so  that  in 
some  parishes  the  mortality  was  no  less  than  1  in  16,  or  even  1  in  14,  of  the 
whole  population.  In  some  parishes  every  tenth  inhabitant  died  from  the  sick- 
ness ;  and  in  many  places,  where  no  medical  aid  could  be  obtained,  the  mortality 
of  the  whole  population  for  the  year  1860  was  1  in  15  or  16.  At  the  same  time 
the  mortality  for  the  town  of  Reykjavik  was  only  1  in  29,  and  for  the  adjacent 
parish  1  in  27.  Being  the  whole  time  obliged  to  go  from  one  hut  to  another, 
and,  besides,  to  make  many  visits  in  the  neighbouring  country,  it  was  impossible 
for  me  to  calculate  the  number  of  my  patients  in  a  perfect  and  accurate  manner. 
I  only  know  this  (as  aforesaid),  that  during  the  years  1858-61  I  have  had  a  num- 
ber of  not  less  than  900  cases  of  typhus  and  typhoid  fever  under  my  treatment, 
and  that  out  of  this  number  I  have  lost  no  more  than  30  patients  from  this  dis- 
ease. In  a  neighbouring  parish  the  number  of  the  patients  was  95,  and  out  of 
this  number  only  two  died.  I  am,  therefore,  inclined  to  believe  that  if  my  dis- 
infecting treatment  had  been  carried  on  under  favourable  circumstances,  the 
result  might  most  probably  have  been  still  more  conspicuous. 

"It  is,  I  think,  an  acknowledged  fact,  that  the  eruptive  and  enteric  typhus 
are  dangerous  fevers ;  and,  although  some  physicians  believe  that  the  eruptive 
typhus  is  less  dangerous  than  the  enteric  typhus,  we  have  in  this  country,  dur- 
ing the  last  epidemia,  proofs  of  its  malignity,  which  led  to  the  enormous  mor- 
tality of  1  in  6  of  the  inhabitants  in  some  places.  Almost  the  same  fatal 
mortality  as  happened  here,  occurred  during  the  last  epidemia  in  the  Westmanna 
Islands.  The  physician  of  that  place  fell  at  the  outbreak  of  the  epidemia  a 
victim  to  the  typhus,  and  out  of  400  inhabitants  40  died  afterwards.  In  some 
parishes  in  the  east  part  of  this  island  it  is  related  that  the  mortality  sometimes 
rose  to  1  in  3  of  the  affected. 

"Mortality  of  typhus  is,  as  we  know,  very  variable,  according  to  the  nature  of 
the  epidemic  constitution  and  other  circumstances.  In  Hooper's  Physician's 
Vademecum,  fifth  edition,  it  will  be  seen,  page  274,  that  the  mortality  of  adyna- 
mic fevers  in  Edinburgh  and  Glasgow  has  very  often  been  1  in  10,  and  even  1  in 
6  or  7,  or  as  great  as  in  some  parishes  of  this  island  during  the  last  epidemical 
typhus.  From  several  articles  in  the  Lancet  I  learn,  moreover,  that  the  mor- 
tality of  typhus  in  the  hospitals  of  London  is  very  often  found  to  be  1  in  10,  or 
even  1  in  8  ;  and,  according  to  Dr.  Trier,  of  Copenhagen,  the  mortality  of  typhus 
and  typhoid  fever  in  that  city  has  generally  been  1  in  8,  or  sometimes  1  in  6. 
In  Germany  and  France  it  is  well  known  that  the  mortality  from  malignant 
fevers  in  the  hospitals  is  generally  1  in  9,  and  sometimes  1  in  7  ;  but  in  Russia, 
namely,  St.  Petersburg  and  Moscow,  it  is  still  less  favourable,  being  in  some 
epidemics  1  in  5. 

"  It  is  generally  accepted  now-a-days,  that  physicians,  before  the  determina- 


\ 


198  Progress  of  the  Medical  Sciences.  [Jan. 

tion  on  the  adoption  of  a  particular  method  of  treatment,  should  always  first 
inquire  what  would  happen  in  this  case  if  no  remedies  whatever  were  employed  ; 
or,  in  other  words,  if  the  patients  were  altogether  left  to  nature,  that  is,  to  the 
efforts  of  their  own  constitution.  Many  renowned  physicians  will  say,  'The 
living  machine,  unlike  the  works  of  human  invention,  has  the  power  of  repairing 
itself.  It  contains  within  itself  its  own  engineer,  who,  for  the  most  part,  in  by 
far  the  greater  number  of  cases,  requires  no  more  than  some  very  slight  assist- 
ance of  our  hands.'  etc.  This  is  the  fashionable  talk  of  the  most  celebrated 
physicians  in  our  time  ;  but  I  have  always  thought  that  this  principle  is  of  as 
little  use  to  medicine  as  it  is  unworthy  of  a  science  which  now  claims  the  name 
of  an  '  exact  learning.'  But  fashion  has  a  strange  power,  and  thus  this  '  inactive 
treatment'  is  become  a  general  rule  amongst  the  physicians  of  Europe  in  our 
century.  In  the  meantime,  it  seems  to  me  that  the  modern  medicine  has  by  this 
principle  involved  itself  in  some  contradictions,  or  why  do  we  then  cure  scurvy 
with  large  doses  of  citric  acid,  inveterate  syphilis  with  large  doses  of  iodide  of 
potassium,  intermittent  fever  with  bark,  rheumatism  by  repeated  doses  of  bicar- 
bonate of  potassa,  lithic  diathesis  and  oxaluria  with  large  doses  of  carbonates 
and  strong  mineral  acids  ?  Why  do  we  at  all  give  remedies  for  poisons  ?  And  if 
we  give  remedies  against  mineral  and  vegetable  poisons,  why  not  also  for  organic 
poisons  ?  I  hope  that  very  few  physicians  will  now-a-days  deny  the  origin  of 
malignant  fevers  from  organic  poison  ;  but,  if  this  is  accepted  to  be  true,  why 
should  we  then  not  try  by  all  possible  means  to  destroy  these  poisons  ?  Pure 
air  is,  no  doubt,  the  most  common  destroyer  of  organic  matter,  and  it  is,  I  think, 
on  this  account  that  the  modern  ventilation  has  done  so  much  good  to  prevent 
and  cure  malignant  fevers.  We  may,  I  hope,  go  still  farther,  and  clean  out  the 
organic  poison  from  the  human  body  by  a  right  use  of  the  principles  of  modern 
chemistry ;  but,  leaving  the  destruction  and  elimination  of  fever  poisons  from 
the  body  to  nature's  efforts  alone,  we  may,  I  think,  very  often  be  mistaken  and 
disappointed. 

"  Regarding  the  melancholy  ravages  of  our  epidemic  typhus  when  it  was 
allowed  to  run  its  own  course,  or  whenever  the  patients  were  unaided  by  the 
medical  interference,  I  can  hardly  doubt  that  my  positive  disinfecting  treatment 
has  been  of  some  value,  and  I  should  indeed  feel  very  happy  if  these  few  remarks 
could  induce  some  of  my  dear  colleagues  to  give  it  a  fair  trial." — Ed.  Med. 
Journ.,  Sept.  1862. 

17.  Treatment  of  Delirium  Tremens. — The  No.  of  the  Edinburgh  Med.  Journ. 
for  November  last,  contains  a  very  interesting  paper  by  Professor  Laycock  on 
the  diagnosis,  prognosis,  and  treatment  of  delirium  tremens.  In  this  paper  Prof. 
L.  advocates,  as  he  did  four  years  since  (Oct.  1858)  in  the  same  journal,  the  ex- 
pectant and  rational  method  of  treatment.  His  views  with  regard  to  the  medical 
treatment  are  marked,  we  conceive,  by  good  sense.  "  Since  a  case  of  delirium 
tremens  tends,"  he  says,  "  independently  of  active  remedies,  to  a  favourable  ter- 
mination in  from  four  to  fourteen  days  (the  cases  I  have  treated  have  averaged 
six  days'  duration),  the  great  indication  of  medicinal  treatment  is  to  favour  this 
tendency  in  expectation  of  early  recovery.  It  is  favoured  by  preventing  as  well 
as  by  helping.  The  natural  impulse  to  interfere  by  the  aid  of  narcotics  and 
stimulants,  or  by  mechanical  means  of  restraint,  has  to  be  checked.  This  is  best 
attained  by  adopting  a  plan  of  treatment  which  occupies  and  gives  confidence 
to  the  'attendants  and  friends,  and  at  the  same  time  calms  the  patient.  The 
effects  of  medicinal  agents  or  drugs  used  to  this  end  cannot  be  satisfactorily 
determined  in  many  cases,  because  we  cannot  say,  when  calm  and  sleep  come 
on,  how  much  is  due  to  the  drug,  how  much  to  the  diet  and  regimen,  and  how 
much  to  nature;  so  that  all  experience  upon  this  point  is  somewhat  doubtful. 
It  is  certain,  however,  that  drugs  have  and  do  exercise  an  influence  over  the 
intensity  of  the  symptoms,  although  they  may  not  either  cause  sleep  or  shorten 
the  duration  of  the  disease.  Of  these,  opium  and  its  salts,  tartar  emetic,  digita- 
lis, chloroform,  purgatives,  alcoholic  and  other  stimulants,  are  examples. 

"  Alcoholic  Stimulants. — These  are  available  in  all  asthenic  forms  of  delirium, 
however  caused.  They  have  been  hitherto  administered  in  the  methystic  form, 
chiefly  on  the  theory  that  the  sudden  withholding  of  the  habitual  stimulant  is 


1863.] 


Medical  Pathology  and  Therapeutics.  199 


the  exciting  cause  of  the  delirium.  The  depression  of  the  nervous  system  may 
be  partly  due  to  the  want  of  the  accustomed  stimulus  ;  but  all  experience  shows 
that  it  is  still  more  commonly  due  to  morbid  causes  of  a  more  general  character, 
such  as  induce  a  feverish  cold,  a  fit  .of  indigestion,  of  the  gout,  or  the  like. 
Without  such  concauses,  abstinence  from  habitual  stimulants  will  not  excite 
delirium  tremens.  The  habitual  drunkard  distinguishes  the  depression  which 
commonly  succeeds  to  stimulation  as  'the  blues;'  'the  horrors' is  a  different 
thing,  and  occurs  when  any  indisposition  induces  loss  of  appetite,  languor,  dis- 
turbed sleep,  and  other  symptoms  of  the  class.  It  is  the  depression  thus  induced 
by  this  same  morbific  cause  which  constitutes  the  first  stage  or  simplest  form 
of  delirium  tremens.  The  intensity,  therefore,  is  partly,  at  least,  determined  by 
•the  kind  of  indisposition  or  acute  affection  ;  and  it  is  this  we  have  to  remedy. 
The  indications,  therefore,  for  the  administration  of  alcoholic  or  habitual  stimu- 
lants must  be  drawn  from  the  then  condition  of  the  patient,  just  as  in  other  dis- 
eases in  which  remedies  of  this  class  are  useful.  When  food  has  not  been  taken 
for  several  days,  and  the  hallucinations  are  of  a  frightful  or  distressing  kind,  and 
especially  when  the  pulse  is  very  quick  and  feeble,  the  first  sound  of  the  heart 
heard  indistinctly,  the  tongue  coated,  cedematous,  and  flat,  or  indented  at  the 
edges,  wine  and  brandy  may  be  administered  medicinally  with  advantage.  Some- 
times this  state  of  prostration  is  due  to  the  combined  influence  of  drinks  and 
opium  or  its  salts,  or  to  opium  alone.  In  either  case,  alcoholic  stimuli  may  be 
given."    *    *  * 

"Opium  and  Salts  of  Morphia. — The  influence  of  these  drugs  is  very  various  ; 
in  one  class  of  cases  having  the  most  beneficial  effect,  in  another  increasing 
greatly  the  excitement  and  delirium.  The  like  difference  in  effect  is  seen  when 
given  in  cases  of  melancholia  and  mania,  for  which  they  have  been  freely  pre- 
scribed. In  some  of  these,  as  in  some  cases  of  delirium  tremens,  very  large,  and, 
under  ordinary  circumstances,  poisonous  doses  have  little  effect.  This  tolerance 
of  opium  in  certain  forms  of  delirium  tremens  has  probably  led  to  its  heroic 
administration  in  cases  generally.  A  question  has  arisen,  whether,  in  those 
thus  treated  which  terminate  fatally,  the  death  is  due  to  the  drug  or  the  disease." 

"  My  own  conclusions  on  this  point  are,  that  the  combination  of  alcoholic 
drinks  with  opium  tends  to  render  the  patient  more  tolerant  of  the  drug ;  that 
in  some  drunkards  its  operation  is  so  much  delayed,  that  when  given  iu  repeated 
doses,  there  is  a  cumulative  effect  produced ;  that  it  is  never  a  wholly  safe  prac- 
tice to  administer  it  for  the  express  purpose  of  procuring  sleep,  nor  as  a  stimu- 
lant in  more  than  the  ordinary  doses  ;  and  that  it  is  always  prudent  to  watch  the 
effect  of  the  remedy  on  the  pupils  in  exciting  contraction.  How  far  various 
other  states  of  the  encephalon  may  antagonize  the  drug,  and  for  how  long,  we 
never  perhaps  can  say,  but  that  there  are  such  states  variously  induced  is  one 
of  the  most  certain  things  in  physic.  We  have  it  in  cases  of  both  mania  and 
melancholia,  in  certain  kinds  of  neuralgia,  in  traumatic  tetanus ;  and  it  is  be- 
lieved that  it  may  be  induced  by  henbane,  belladonna,  and  other  drugs.  And  it 
is  to  be  remembered  that  the  antagonizing  state  may  be  so  transient  as  to  leave 
the  brain  exposed  to  the  full  action  of  the  poison  before  it  is  eliminated — nay, 
by  its  action  on  other  viscera  may  delay  the  elimination."    *    *  * 

"  Camphor. — It  is  not  easy  to  determine  beforehand  when  opium  or  its  salts 
serve  only  to  induce  greater  prostration  and  distress ;  most  generally,  however, 
the  patient  is  of  a  nervous  habit  with  a  florid  complexion,  or  at  least  has  had, 
and  is  of  a  neuro-vascular  diathesis.  In  cases  of  this  kind  where  the  exhaustion 
is  great  and  morphia  inadmissible,  camphor  proves  sometimes  useful,  in  from 
two  to  three  grains  every  three  hours,  or  the  carbonate  of  ammonia  combined 
with  camphor  and  henbane. 

11  Mental  Hypnotics  are  singularly  successful  in  those  cases  in  which  there  is 
a  morbid  apprehension  as  to  sleepless  nights,  and  a  hypochondriacal  anxiety  for 
sleep.  It  is  often  the  morbid  feeling  alone  which  prevents  sleep:  this  is  proved 
by  the  circumstance,  as  repeatedly  witnessed  in  my  practice,  that  any  simple 
remedy  administered  to  the  patient  so  as  to  impress  him  with  the  conviction 
that  it  will  cause  sleep,  is  followed  by  sleep  ;  and  sometimes,  when  convalescence 
is  approaching,  by  as  prolonged  a  sleep  as  if  a  powerful  narcotic  had  been  taken. 


200 


Progress  of  the  Medical  Sciences. 


[Jan. 


In  one  case  of  this  kind  the  long  sleep  which  followed  upon  a  placebo  excited 
alarm. 

"Tartar  Emetic. — This  drug,  like  -opium,  has  been  administered  in  large  doses 
in  delirium  tremens ;  the  effect  of  which,  I  venture  to  say,  can  only  be  to  excite 
gastric  or  gastro-enteric  inflammation.  Now,  it  is  probable,  counter-irritation 
of  the  gastro-intestinal  mucous  membrane  is  very  beneficial  in  some  cerebral 
affections.  Perhaps  calomel  sometimes  acts  in  this  way  in  acute  hydrocephalus ; 
but  in  the  majority  of  cases  of  delirium  tremens  this  result  is  attained  by  a 
simple  purgative,  and  care  should  be  taken  to  avoid  irritating  the  already  irri- 
tated stomach.  Tartar  emetic,  therefore,  should  be  administered  in  solution,  and 
in  doses  not  exceeding  30  minims  of  the  liquor  of  the  Pharmacopoeia.  It  is 
chiefly  indicated  in  those  cases  in  which  there  is  some  inflammatory  complica- 
tion,, and  especially  pneumonia,  however  trifling.  It  is  advantageous,  too,  at  an 
early  period  in  those  in  which  the  whole  character  of  the  disease  is  more  sthenic, 
and  the  mental  disorder  more  nearly  approaches  insanity  or  mania.  In  these 
the  patient  is  less  apprehensive  and  timid;  often  loquacious,  suspicious,  and 
inclined  to  be  aggressive  upon  slight  provocation ;  he  has  notional  delusions 
more  predominantly  than  hallucinations  of  the  senses;  his  nights  are  disturbed, 
but  not  wholly  sleepless  ;  nor  has  he  tremors  of  importance.  His  appetite  com- 
paratively with  the  asthenic  form  is  little  impaired ;  his  tongue  but  little  coated, 
and  when  projected  rather  pointed  and  firm,  than  flat,  flabby,  and  tremulous. 
His  skin,  too,  is  rather  hot,  or  at  least  natural,  than  cool  and  moist ;  and  the 
pulse  is  less  round,  undulating,  and  quick.  Cases  of  this  kind  are  intolerant  of 
stimulants  and  opium  even  in  small  doses,  these  being  apt  to  change  a  '  cantank- 
erous' kind  of  delirium  into  a  raving  or  destructive  sort ;  whereas  20  to  30 
minims  of  tartar  emetic  liquor,  given  every  three  or  four  hours,  calm,  or  at  least 
do  not  aggravate.  When,  however,  there  are  symptoms  of  depression,  especi- 
ally in  a  young  person,  and  the  history  is  that  of  causes  of  exhaustion,  laudanum 
in  5  to  15  minim  doses  is  a  useful  stimulant,  in  combination  with  15  to  20  minims 
of  the  liquor.  This  has  long  been  found  useful  in  ordinary  maniacal  delirium 
thus  arising. 

"  Emetics,  Purgatives,  and  Stomachics. — Methods  of  treatment  by  purgatives, 
quinine,  and  tonics  have  been  recommended.  The  patient  before  coming  under 
treatment  has  usually  tried  remedies  of  this  class,  especially  bitter  drugs,  either 
as  bitter  tinctures,  '  the  bitters'  of  the  dram-shop,  or  in  bitter  beers.  The  effect 
of  these  is  to  modify  the  symptoms,  and  especially  to  induce  muscular  twitch- 
ings,  tremors,  and  even  slight  convulsive  attacks.  Yery  often  in  such  there  has 
been  a  total  loss  of  appetite,  and  no  food  has  been  taken  for  several  days.  In 
some,  food  is  vomited,  in  others,  if  retained,  it  causes  pain,  because  of  the  state 
of  the  mucous  membrane  of  the  stomach.  This  is  often,  in  fact,  congested  and 
inflamed.  Hence  the  dietetic  and  medicinal  treatment  of  gastritis  is  indicated ; 
constipation  and  hepatic  congestion  are  not  uncommon  complications,  and  indi- 
cate a  suitable  aperient.  Podophyllin,  calomel,  colocynth,  and  henbane,  castor 
oil,  salts,  and  senna,  and  Gregory's  powder,  were  the  ordinary  remedies  of  this 
kind  used  in  the  infirmary.  Of  the  new  drug  as  a  bilious  purgative  I  can  speak 
favourably.  Podophyllin  was  prescribed  in  several  cases  in  combination  with 
cannabis  indica  or  henbane,  with  good  effect.  The  following  formulae  were  used: 
li.  Podophylli,  gr.  ij ;  pulv.  cinnamomi  co.,  extract  hyoscyami,  aa  9  ;  mucil.,  q.  s. 
The  mass  to  be  made  into  four  pills,  of  which  one  to  be  taken -every  six  hours 
until  the  bowels  were  moved.  In  another  formula,  gr.  viij  of  powdered  ginger, 
and  of  extract  of  cannabis  indica  were  Combined  with  gr.  iij  of  podophyllin,  and 
made  into  six  pills.  The  purgatives,  of  whatever  kind,  were  always  given  at  the 
commencement  of  the  treatment  and  not  afterwards.  Emetics  were  never  tried, 
and  were  never  indicated  except  in  cases  of  drunkenness.  Stomachics  were 
prescribed  in  a  few  cases  at  the  termination,  when  convalescence  was  established, 
but  were  rarely  needed. 

■  Digitalis  and  Chloroform. — There  is  evidence  of  the  calming  effect  of  digi- 
talis, but  it  is  of  the  vaguest  kind.  There  is  no  indication  of  the  class  of  cases 
in  which  it  may  be  safely  prescribed,  nor  are  we  clearly  informed  whether  in  the 
cases  reported  there  was  not  renal  or  cardiac  disease,  or  the  complication  of 
drunkenness  or  of  narcotization.    I  have  seen  it  tried  in  one  case,  in  which,  in 


/ 


1863.]  Medical  Pathology  and  Therapeutics.  201 


consultation  with  a  medical  friend,  it  was  resolved  to  try  a  half  ounce  dose  of 
the  tincture.  The  patient  had  had  a  drinking  bout,  aod  suddenly  became 
aggressive  and  destructive,  tearing,  pulling  down,  and  burning,  and  striking  and 
throwing  things  at  the  attendants.  There  was  no  loquacity  :  the  patient  rarely 
spoke,  but  sat  in  bed,  rolling  up  the  bedclothes,  tearing  off  his  clothing,  and 
throwing  food  and  drink  in  the  faces  of  those  who  offered  it.  This  he  did  with 
his  dose  of  tincture  of  digitalis,  after  drinking  one-half  of  it.  The  case  was  one 
in  which  the  expectant  treatment  was  thereupon  tried  with  entire  success — -rea- 
son being  restored  and  convalescence  established  within  the  week.  Chloroform 
has  been  administered  in  very  violent  cases  with  advantage  :  when  exhaustion 
is  likely  to  come  on  from  the  constant  raving  and  struggles  of  the  patient,  it 
may  save  life  by  saving  strength.  Such,  however,  are  rare,  and  are  more  fre- 
quently met  with  as  the  result  of  heroic  treatment  than  in  the  ordinary  course 
of  the  disease. 

"  There  were  two  or  three  cases  of  puerperal  mania  (so  called)  admitted  into 
the  Infirmary  and  Milnholm  Asylum  during  the  summer,  and  were  treated  on 
the  same  principles  as  the  cases  of  delirium  tremens.  One  of  these  brought  to 
the  infirmary  had  fallen  into  a  raving  delirium  after  taking  morphia.  They  were, 
in  truth,  acute  cerebral  affections,  of  which  parturition,  or  the  puerperal  state, 
was  the  exciting  cause,  and  recovered  within  a  short  period.  How  far  albumi- 
nuria is  a  cause  or  an  effect  of  the  morbid  state  of  the  encephalon,  in  this  class 
of  cases,  has  yet  to  be  determined,  although  it  is  commonly  assumed  to  be  the 
cause.  In  none  of  the  cases  I  have  treated  was  there  any  important  renal  com- 
plication, nor  was  albuminuria  detected,  although  the  urine  was  carefully  ex- 
amined. Renal  disease,  especially  albuminuria,  is  amongst  the  rarer  complica- 
tions of  insanity." 

18.  Anaesthesia  caused  hy  Diseases  of  the  Lungs. — M.  Bouchut  long  ago 
remarked  the  fact,  that  the  approach  of  asphyxia  in  the  latter  stages  of  croup 
brought  with  it  a  condition  of  lowered,  and  finally  of  extinguished  sensibility. 
He  now  produces  examples  of  other  diseases,  to  show  that  the  law  is  a  general 
one,  that  asphyxia  is  always  accompanied,  pari  passu,  by  anaesthesia;  and  this 
anaesthesia  is  quite  independent  of  any  diminution  of  consciousness.  The  most 
interesting  of  his  cases  is  that  of  a  young  man,  a  student,  who  was  attacked 
with  a  most  profuse  and  suffocating  haemoptysis.  During  several  hours  he  was 
in  a  condition  of  extreme  asphyxia,  and  although  his  intellect  remained  clear, 
he  had  complete  anaesthesia,  and  curiously  enough,  even  an  erection  of  the  penis 
and  discharge  of  semen  such  as  frequently  occurs  in  persons  who  are  hanged. 
The  other  examples  cited  of  anaesthesia  occurring  in  the  course  of  respiratory 
affections,  are  cases  of  croup,  capillary  bronchitis,  &c. — London  Med.  Rev., 
Oct.  1862,  from  Gazette  des  Hopitaux. 

19.  Therapeutics  of  Consumption. — Dr.  Cotton,  in  a  paper  read  before  the 
Medical  Society  of  London  (Oct.  20,  1862)  presented  the  results  of  some  expe- 
riments which  he  has  been  carrying  on  for  the  last  five  years  at  the  Hospital  for 
Consumption,  Brompton,  upon  the  action  of  certain  medicinal  substances  upon 
phthisis.  He  had  exhibited  the  following  substances,  each  in  twenty-five  cases 
of  simple  uncomplicated  consumption— viz.,  phosphorus,  liquor  potassae,  hydro- 
chloric acid,  iodide  of  iron,  iodide  of  potassium,  chloride  of  sodium,  vinum  ferri, 
glycerine,  sesquichloride  of  iron,  chlorate  of  potash,  quinine,  and  phosphoric 
acid.  The  results  were  numerically  stated  upon  a  table  which  was  exhibited. 
The  phosphorus  was  administered  in  doses  of  about  one  twenty-fifth  of  a  grain 
two  or  three  times  a  day ;  in  a  few  cases  it  seemed  to  do  good,  but  more  gene- 
rally its  effect  was  unsatisfactory.  *Liquor  potassae  was  productive  of  very  little 
good,  and  presented  a  marked  contrast  to  the  dilute  hydrochloric  acid,  which 
evidently  contributed  in  many  instances  to  marked  improvement  in  the  patients ; 
only  12  per  cent,  of  those  who  had  taken  the  potash  having  been  benefited, 
whilst  68  per  cent,  of  those  who  had  taken  the  hydrochloric  acid  received  more 
or  less  good.  Amongst  the  latter  were  some  very  decided  cases.  Iodide  of 
potassium  contributed  but  few  cases  of  improvement,  its  effects  being  generally 
of  a  negative  character.    Iodide  of  iron,  however,  made  a  very  respectable  addi- 


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tion  to  the  list  of  improved  cases.  In  many  instances  chloride  of  sodium  acted 
favourably  as  a  tonic,  both  the  appetite  and  general  power  of  the  patients 
appearing  to  increase  under  its  use.  Steel  wine  was  productive  of  very  good 
results,  especially  in  children  and  young  persons.  The  author  appeared  to  place 
great  faith  in  its  use,  particularly  when  given  with,  or  immediately  after,  meals. 
Glycerine  failed  very  generally,  and  its  effects  could  bear  no  comparison  with 
cod-liver  oil,  both  these  substances  having  carefully  weighed  one  with  the  other. 
Of  all  remedies  the  sesquichloride  of  iron  seemed  the  most  effective,  a  consider- 
able number  of  patients  (66  per  cent.)  having  derived  more  or  less  advantage 
from  its  use.  Dr.  Cotton  stated  that  both  in  his  hospital  and  private  practice 
he  had  long  regarded  this  as  one  of  the  most  useful  agents  in  the  treatment  of 
the  ordinary  run  of  consumptive  patients.  Chlorate  of  potash  proved  useful  in 
many  of  the  very  cachectic  cases;  but  it  was  far  from  a  "specific" — a  title  given 
to  it  by  more  than  one  medical  practitioner.  Quinine  was  less  effective  than  many 
other  tonics,  although  it  did  good  in  a  small  proportion  of  cases.  Steel  and  qui- 
nine, however,  were  spoken  of  by  the  author  in  very  laudatory  terms.  Phosphoric 
acid  acted  as  a  tonic  in  a  certain  number  of  cases,  but  was  inferior  to  other 
mineral  acids,  especially  the  hydrochloric.  The  author  carefully  explained  that 
the  table  he  had  exhibited  showed  rather  the  comparative  than  the  absolute 
value  of  the  remedies  he  had  given,  since  it  was  impossible  to  separate  from  its 
share  in  the  results  the  combined  action  of  hope,  rest,  good  diet,  and  general 
hygiene,  which  at  the  Consumption  Hospital  form  an  important  part  of  the 
treatment. 

The  following  are  amongst  the  conclusions  which  Dr.  Cotton  wished  to  draw 
from  the  facts  he  had  detailed: — 

1st.  That  since,  during  the  administration  of  each  one  of  the  agents  he  had 
experimented  upon,  several  cases  were  observed  to  run  through  the  various 
phases  of  the  disease,  some  to  a  fatal  termination,  it  is  obvious  that,  whatever 
the  amount  of  benefit  which  in  some  cases  followed  their  use,  no  one  of  such 
agents  deserves  the  title  of  "specific." 

2d.  It  may  fairly  be  concluded  that  the  good  effected  by  any  of  these  agents 
was  due  to  their  respective  tonic  and  upholding  influence  upon  the  general 
system. 

3d.  In  the  majority  of  phthisical  cases,  steel — especially  the  sesquichloride  of 
iron — and  the  mineral  acids  appear  to  be  the  most  effective;  but  tonics  generally 
are  productive  of  more  or  less  improvement. 

4th.  Since,  however,  even  steel  and  mineral  acids,  as  well  as  other  useful 
tonics,  are  undoubtedly  inert  in  a  certain  proportion  of  cases,  it  is  not  improba- 
ble that  there  are  varieties  or  modifications  of  phthisis,  each  of  which  may 
require  a  particular  treatment.  As  there  are  special  varieties  of  many  other 
diseases  requiring  special  modes  of  treatment,  and  yielding  to  none  other,  it  is 
possibly  the  same  with  consumption. 

Dr.  Cotton  observed,  in  conclusion,  that  we  are  too  apt  to  consider  and  to 
treat  phthisis  as  a  separate  and  always  similar  disease,  forgetting  the  almost 
endless  varieties  or  modifications  it  presents;  and  stated  his  conviction  that  at 
no  distant  period  of  time  consumption,  like  many  other  diseases,  will  be  shown 
to  present  definite  and  special  forms,  each  of  which  requires  definite  and  special 
management. — Lancet,  Oct.  25,  1862. 

20.  Pleuritic  Effusions,  viewed  in  Relation  to  Thoracentesis. — Dr.  Henley 
Tiior  p  has  published  (Dublin  Quarterly  Journ.  Med.  Sc.,  Aug.  1862)  some 
interesting  observations  on  this  subject,  illustrated  by  two  cases  in  which  thora- 
centesis was  successfully  performed. 

The  objects  of  Dr.  TVs  observations  are — 1st.  To  sketch  briefly  the  particular 
morbid  states  that  may  call  for  the  performance  of  thoracentesis ;  and  2d.  To 
indicate  what  he  conceives  to  be  the  just  pathological  principle  which  should 
guide  us  in  our  mode  of  performing  the  operation. 

"  The  most  extraordinary  fact  connected  with  the  history  of  paracentesis 
thoracis  is,"  Dr.  T.  observes,  "the  variable  amount  of  success  that  has  hitherto 
attended  it  in  different  hands — the  most  discordant  results  have  been  obtained 
by  men  of  equal  experience,  and  possessing  similar  advantages  for  observation — 


1863.] 


Medical  Pathology  and  Therapeutics. 


203 


nevertheless,  although  individual  opinion  has  differed  so  widely  respecting  the 
merits  of  the  operation,  it  is  now  demonstrated  that  its  general  result  is  most 
encouraging,  whether  considered  as  a  curative  or  merely  palliative  measure. 
The  very  important  contributions  of  Bennett,  Hughes,1  Hamilton  Koe,2  and 
Phillips,3  [Dr.  T.  should  have  added — and  of  Dr.  Bowditch],  place  the  statistics 
of  the  operation  in  a  very  favourable  position,  and  have  contributed  in  a  great 
measure  to  remove  the  erroneous  views,  respecting  its  danger,  rather  generally 
entertained  by  the  profession.  Nevertheless,  much  diversity  of  opinion  still 
exists  as  to  when  and  in  what  cases  thoracentesis  ought  to  be  performed. 

"  I  think  the  following  enumeration  will  be  found  to  embrace  nearly  all  the 
conditions  under  which  the  proceeding  is  likely  to  be  contemplated.:  Cases  of 
hyperacute  pleurisy,  attended  with  rapid  effusion  and  eccentric  pressure,  so 
formidable  as  to  threaten  suffocation ;  cases  of  pleurisy  in  which,  after  the  ordi- 
nary treatment  has  failed  to  remove  the  effusion,  the  latter  remains  either 
stationary  or  increases ;  in  empyema  proper,  or  pyothorax,  when  the  strength 
of  the  patient  is  unable  to  bear  up  against  the  suppurative  crisis,  or  asphyxia  is 
imminent ;  in  cases  of  chronic  pleurisy,  or  latent  effusions,  occurring,  for  the 
most  part,  in  young  subjects,  after  the  failure  of  ordinary  measures  ;  unabsorbed 
effusions  incident  to  Bright's  disease,  attended  with  dangerous  thoracic  distress; 
pleural  collections,  persisting  as  sequels  of  the  exanthemata,  or  continued  fever; 
passive  dropsy  of  the  pleura,  attended  with  symptoms  of  impending  suffocation, 
complicating  organic  disease  of  the  heart  and  lungs  ;  certain  cases  of  pyopneu- 
mothorax produced  by  the  sudden  bursting  of  vomicae  into  the  pleural  sac ; 
some  examples  of  the  same  condition,  the  consequence  of  sloughing  of  the  lung 
and  pleura ;  traumatic  lesions,  where  the  presence  of  blood,  air,  pus,  or  other 
effusions  is  productive  of  hazardous  pressure  irremediable  by  other  means. 

"From  a  glance  at  the  foregoing  category  it  must  appear  obvious  that  no 
approach  to  a  uniformity  of  symptoms  or  physical  signs  can  be  arrived  at  as  an 
indication  for  the  operation ;  the  whole  series,  however,  as  respects  the  remedy 
in  question,  may  be  arranged  into  three  groups  : — 

"  1.  Cases  in  which  thoracentesis,  in  the  absence  of  symptoms  of  immediate 
urgency,  may  be  employed  as  a  curative  measure. 

i(  2.  Cases  in  which  the  operation  can  only  be  considered  as  a  palliative  remedy. 

"  3.  Cases  in  which  it  may  be  had  recourse  to  as  a  dernier  ressort. 

"  I  apprehend  that  the  greater  number  of  the  conditions  above  specified  are 
such  as  would  be  considered,  by  the  majority  of  practitioners,  beyond  all  hope 
of  cure,  or  even  relief,  from  any  operative  measure,  still  I  cannot  avoid  enter- 
taining a  belief  that  the  value  of  thoracentesis,  rendered  more  perfect  and  safe 
as  the  mode  of  performing  it  comes  to  rest  upon  sounder  principles  than  hereto- 
fore, will  by-and-by  be  generally  recognized  by  the  profession ;  and  that  the 
operation  will  be  practised  earlier  and  oftener,  and  on  the  whole,  perhaps,  with 
fewer  misgivings  as  to  the  ultimate  issue  than  paracentesis  abdominis,  which  is, 
with  very  few  exceptions,  only  had  recourse  to  as  a  palliative  remedy." 

In  connection  with  the  various  plans  proposed  for  tapping  the  chest,  Dr.  T. 
considers  that  "  a  point  of  paramount  importance  has  failed  to  receive  from 
surgeons  the  consideration  it  deserves,  namely,  the  physical  characters  of  the 
fluid  to  be  evacuated.  Each  practitioner  recommends  a  particular  mode  of 
operating,  without  any  reference  whatever  to  the  quality  of  the  pleural  contents. 
Would,  I  may  ask,  collections  in  other  parts  of  the  body  of  serous,  sero-sangui- 
neous,  sero-albuminous,  and  purulent  fluids  be  treated  alike,  and  by  the  same 
surgical  procedure  ?  Do  not  surgeons  every  day  practically  recognize  the  dif- 
ference between  chronic,  cold,  acute,  symptomatic,  and  other  abscesses  and  col- 
lections, and  act  accordingly  ?  How  comes  it  that  pleural  effusions,  of  whatever 
character,  should  be  placed  in  the  anomaly  of  having  only  one  plan  of  proceeding 
applicable  to  them  ?  Surely  here  must  be  an  oversight.  Until  lately  surgeons 
had  an  unfounded  dread  of  opening  even  acute  purulent  collections  in  certain 


1  Guy's  Hospital  Reports,  vol.  ii.,  new  series,  1844. 

2  Medico-Chirurgical  Transactions,  vol.  xxvii.  p.  198.  1S44. 

3  Medico-Chirurgical  Transactions,  vol.  xxvii. 


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Progress  of  the  Medical  Sciences. 


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localities — for  example,  in  connection  with  the  larger  joints.  This  prejudice, 
however,  is  fast  dying  away ;  and  if  the  practice  first  insisted  upon  by  Mr.  Gay 
were  oftener  and  more  promptly  executed  we  should  have,  perhaps,  fewer  cases 
of  1  resection,'  an  innovation  which  has  of  late  years  become  so  very  fashionable. 

"  Let  us  endeavour,  then,  to  apply  the  common  principles  of  pathology  to  the 
treatment  of  hydrothorax  and  empyema,  and  seek  to  apprehend  correctly  the 
ordinary  operations  of  nature  in  the  removal  of  these  diseases.  How  does  the 
spontaneous  cure  of  pyothorax  take  place  ?  Here  as  elsewhere  the  purulent 
matter  tends  to  the  surface,  and  is  either  discharged  into  the  bronchi  or  pene- 
trates the  chest-wall  through  an  intercostal  space ;  atmospheric  air  has  access 
to  the  sac  of  the  abscess  ;  gradually  the  suppurative  action  lessens  as  the  cavity 
contracts  ;  and,  if  the  strength  of  the  patient  be  equal  to  the  effort,  a  cure  is 
effected.  How  differently  does  nature  proceed  in  her  task  of  eliminating  serous, 
sero-albuminous,  and  non-purulent  collections  in  the  same  locality.  These  latter 
are  never  discharged  as  such  in  the  manner  just  described ;  they  are  either 
directly  absorbed,  or  of  necessity  undergo  the  purulent  transformation  prepara- 
tory to  their  opening;  into  the  lungs,  or  externally.  May  not  these  considerations 
be  suggestive  as  to  the  most  eligible  mode  of  performing  thoracentesis  in  differ- 
ent instances,  and  moreover  throw  some  light  upon  the  long-debated  question  of 
the  influence  of  atmospheric  air  when  admitted  into  the  pleural  cavity. 

"It  is  almost  superfluous  to  remark,  that  some  operators  suppose  this  gaseous 
body  to  possess  a  most  pernicious  influence,  whilst  others  believe  it  to  be  per- 
fectly innocuous.  That  atmospheric  air  itself  exerts  no  irritating  influence  on 
the  tissues  of  the  body  is  rendered  pretty  evident  by  the  phenomena  of  general 
emphysema,  as  also  of  simple  pneumothorax,  whether  traumatic  or  occurring  as 
a  consequence  of  rupture  of  a  dilated  air  vesicle  ;  although  the  cellular  tissue  of 
the  body  may  be  inflated  so  as  to  resemble  a  'stuffed  skin,'  and  the  pleura  dis- 
tended almost  to  bursting,  no  erethism  or  reactive  inflammation  is  the  conse- 
quence of  the  lesion.  But  that  atmospheric  air,  on  some  occasions,  does  exert 
a  deleterious  effect  is  unquestionable ;  but  it  so  acts,  not  by  reason  of  its  stimu- 
lating properties,  but  simply  because  it  supplies  one  of  the  conditions  under 
which  putrefaction  of  purulent  and  other  fluids  is  likely  to  occur.  Not  that  its 
presence  is  invariably  followed  by  the  chemical  change  in  question.  Laennec 
gives  the  case  of  a  patient  affected  with  broncho-pleural  fistula,  who  for  six  years 
exhibited  the  signs  of  hydro-pneumothorax  without  either  local  or  constitutional 
distress.  Louis,  and  various  other  physicians,  have  witnessed  similar  instances. 
In  truth  the  precise  conditions  under  which  putrefactive  changes  are  generated 
in  the  pleura  have  yet  to  be  determined ;  insomuch  so  that  we  are  forced  to 
admit,  in  addition  to  the  acknowledged  influence  of  heat  and  air,  the  presence 
of  some  unknown  agent  or  state  which  disposes  the  fluid  contents  to  undergo 
catalytic  changes — or  how  explain  the  cause  of  the  latter  not  taking  place  in 
the  cases  just  referred  to  ?  Enough,  however,  is  known  to  warrant  the  exercise 
of  great  caution  in  performing  paracentesis  so  as  to  prevent  the  ingress  of 
atmospheric  air  in  certain  pleuritic  effusions  of  the  non-suppurative  class;, 
whereas  purulent  collections  in  the  cavity  of  the  chest  should  form,  in  my 
opinion,  no  exception  to  the  ordinary  manner  of  dealing  with  similar  diseases 
elsewhere. 

"  In  short,  I  would  apply  to  pyothorax,  or  pure  empyema,  the  surgical  prin- 
ciple, to  which  there  are  few  exceptions  in  acute  or  subacute  suppurations ;  that 
of  discharging  the  abscess  by  a  free  opening.  Here,  however,  it  is  necessary  to 
inquire  where  the  perforation  should  be  made  when  the  case  admits  of  a  point 
of  election  ?  and  we  may  not  act  unwisely  by  interrogating  the  vis  medicatrix 
on  this  head.  When  spontaneous  openings  occur,  are  they  not  generally  found 
anteriorly  and  high  up  ?  Nature  then  indicates  these  positions  as  being  the 
most  eligible  by  her  own  operations.  Nor  is  the  object  of  her  method  obscure 
or  unintelligible.  By  causing  the  liquid  contents  to  proceed  from  below  upwards 
she  guards  against  the  sudden  evacuation  of  a  cavity  (and  consequent  entrance, 
and  imprisonment  of  atmospheric  air  in  proportionate  volume)  the  walls  of  which 
can  only  approximate  by  slow  degrees ;  thus  the  suppurating  sac  is  emptied 
gradually  by  its  own  contraction ;  and  the  air,  which  can  only  enter  in  small 
quantity,  has  free  egress,  being  always  uppermost,  and  in  close  proximity  with 


1863.]  Medical  Pathology  and  Therapeutics. 


205 


the  discharging  orifice.  "We  should  therefore,  in  conformity  with  these  prin- 
ciples, not  open  the  chest  in  a  depending  position  ;  for,  if,  unfortunately,  after- 
wards, putrefactive  changes  take  place,  the  septic  gases  floating  above  the  other 
contents  have  no  exit,  are  absorbed  by  the  lining  membrane  of  the  cavity,  excite 
inflammation  of  the  latter,  contaminate  the  blood,  and  produce  typhoid  symp- 
toms. To  prevent,  then,  putrid  absorption,  and  its  concomitant  evils,  let  the 
empyema  be  opened  above — that  is  to  say  (when  the  case  admits  of  our  doing 
so),  between  the  fourth  and  fifth  ribs,  anteriorly,  and  provide,  if  necessary,  for 
the  constant  drainage  of  the  abscess  by  the  introduction  of  a  Chassaignac's  tube.1 

"  In  cases,  however,  of  hydrothorax,  or  sero-albuminous,  sero-sanguineous, 
and  passive  collections  in  the  pleural  sac,  our  operative  proceedings  should  be 
guided  by  very  different  principles.  In  pyothorax  a  pyogenic  membrane  is 
already  formed,  and  matter  is  making  its  way  to  the  surface  ;  by  evacuating  the 
collection  we  only  complete  an  operation  already  commenced.  But  the  other 
class  of  effusions  referred  to  are  very  differently  circumstanced;  they  are  not 
included  in  an  adventitious  sac,  or  newly  organized  membrane,  but  lie  in  con- 
tact with  the  serous  surface  in  a  healthy  condition,  or  only  slightly  altered  in 
anatomical  structure  and  vital  endowments ;  the  fluid  evinces  no  tendency  to 
reach  the  surface ;  if  it  disappear  it  is  directly  absorbed  from  the  serous  cavity, 
and  is  never  evacuated  externally  without  having  previously  undergone  more 
or  less  of  purulent  metamorphosis.  Therefore  we  should  endeavour,  in  dealing 
with  these  immature  collections,  to  avoid  all  causes  of  irritation,  and  to  prevent, 
by  all  means  in  our  power,  the  higher  or  suppurative  grade  of  action  not  yet 
attained  under  existing  conditions  ;  in  short,  we  should  make  the  practice  of  art 
approach  as  closely  as  possible  to  nature's  own  operations,  and  not  proceed  in 
untimely  advance  of  them.  Accordingly  the  fluid  ought,  only  in  the  first  in- 
stance, to  be  partially  withdrawn  ;  the  remainder  may  be  absorbed  into  the  sys- 
tem ;  if  not,  the  tapping  may  be  repeated.  Valvular  perforation  of  the  integu- 
ments and  the  employment  of  a  vulcanized  India  rubber  bag  and  stopcock,  or 
the  ingenious  trocar  and  canula  invented  by  Mr.  Charles  R.  Thompson,  will 
effectually  prevent  the  entrance  of  atmospheric  air.2 

"By  proceeding  in  this  manner  we  do  not  overstrain  the^ vital  processes  of 
the  economy  in  their  progress  towards  the  restoration  of  health,  but  only  disen- 
cumber them  of  impediments  that  check  their  free  action,  and,  with  full  con- 
fidence in  her  resources,  leave  Nature  to  complete  the  cure  by  the  continuance 
of  her  own  efforts. 

"  We  first  endeavour  to  comprehend  the  purposes  and  modus  operandi  of  the 
vis  medicatrix,  and  then  follow  faithfully  in  her  path,  without  seeking,  by  pre- 
mature interference,  to  reverse  the  natural  order  of  pathological  events,  or  force 
upon  her  contingencies  for  which  she  is  as  yet  unprepared." 

21.  On  Tobacco  as  a  Cause  of  Angina  Pectoris. — Among  the  bad  effects 
produced  by  the  excessive  use  of  tobacco  may  be  mentioned  vertigo,  chronic 
sore  throat,  dyspepsia,  and  cough  accompanied  with  emaciation  simulating 
phthisis.  To  these  morbid  conditions  we  must  now,  according  to  Dr.  Beau,  add 
angina  pectoris.  This  opinion  is  founded  upon  eight  observations  contained  in 
an  interesting  paper  lately  laid  before  the  Academy  of  Sciences.  These  facts 
have  an  additional  value  because  they  agree  perfectly  with  the  experiments  of 


1  It  may  be  necessary,  in  certain  cases,  to  make  a  counter  opening  inferiorly, 
and  draw  the  tube  completely  across  the  cavity.  This  plan  of  "  drainage"  has 
been  adopted  in  two  instances,  by  Dr.  Groodfellow,  with  signal  success.  He  reports 
them  in  the  42d  .volume  of  the  Medico-Chirurgical  Transactions.  The  practice, 
also,  of  iodine  injections,  after  the  cavity  has  been  reduced  to  the  condition  of  a 
fistula,  is  well  worthy  of  trial. 

2  As  suppurative  action  is  not  anticipated  in  the  mode  of  operating  referred  to 
in  the  text,  the  point  of  election  need  not,  as  in  pyothorax,  deviate  from  that  gene- 
rally selected — namely,  between  the  fifth  and  sixth  or  sixth  and  seventh  ribs,  and 
midway  between  the  sternum  and  spine.  When  any  doubt  exists  as  to  the  nature 
of  the  fluid,  the  introduction  of  Dr.  Babington's  explorator  will  be  found  preferable 
to  the  grooved  needle  in  ordinary  use. 


206 


Progress  op  the  Medical  Sciences. 


[Jan. 


M.  Claude  Bernard  upon  nicotine,  and  are  illustrations  of  the  doctrine  which 
considers  angina  pectoris  as  being  an  affection  of  the  muscular  substance  of  the 
heart,  with  irradiations  in  the  thorax,  the  neck,  and  the  upper  extremities. 

M.  Bernard  has  proved  that  nicotine,  a  poisonous  alkaloid  as  powerful  as 
prussic  acid,  though  acting  in  a  different  manner,  produces  its  principal  effects 
upon  the  nerves,  upon  the  muscles,  but  especially  upon  the  vascular  system. 
In  a  moderately  strong  dose,  this  substance  produces  in  the  muscles  convulsive 
movements  which  may  terminate  in  a  permanently  tetanic  condition ;  whilst,  if 
the  dose  is  small,  the  first  effects  are  produced  upon  the  heart  and  lungs,  giving 
rise  to  acceleration  of  the  respiration,  and  increased  energy  of  the  cardiac  pul- 
sations. A  clear  proof  that  the  nerves  are  the  organs  of  transmission  of  this 
complicated  action  is,  that  after  the  division  of  the  pneumogastric  none  of  these 
phenomena  are  manifested.  It  is  important  to  add,  that  the  action  upon  the 
muscular  system  is  produced  exclusively  when  the  nicotine  is  pure  and  in  suffi- 
cient quantity ;  whilst,  if  it  is  diluted  or  mixed,  it  acts  specially  upon  the  respi- 
ratory apparatus  and  the  heart. 

Of  course,  Dr.  Beau  does  not  suppose  that  the  abuse  of  tobacco  is  the  only 
cause  of  angina.  On  the  contrary,  he  says,  that  the  causes  of  this  affection  are 
numerous,  and  he  has  only  pointed  out  an  additional  cause  which  had  not  been 
previously  attended  to.  He  also  adds  that  for  the  production  of  angina  among 
smokers  a  series  of  conditions  is  required,  which  is  only  rarely  met  with.  These 
conditions  are  :  1st,  the  excessive  use  of  tobacco  ;  2d,  a  special  susceptibility 
of  the  individual;  3d.  debilitating  influences,  such  as  anxiety,  fatigue,  an 
enfeebled  condition  of  the  disgestive  organs,  etc.,  which,  preventing  the  organ- 
ism from  getting  rid  of  the  tobacco  absorbed,  allow  it  to  accumulate  to  such  a 
degree,  that  nicotine  is  present  in  sufficient  quantity  to  produce  its  poisonous 
influence  upon  the  heart. 

The  following  are  the  observations  appealed  to  by  Dr.  Beau. 

1st.  A  small  proprietor,  sixty  years  of  age,  passed  the  greater  part  of  his 
time  in  smoking.  For  about  a  month  he  had  often  experienced,  during  the 
night,  attacks  of  palpitation,  with  oppression  and  pain  radiating  to  his  shoul- 
ders. He  ceased  smoking;  the  nocturnal  attacks  disappeared  completely  at 
the  same  time  that  his  digestive  functions  improved.  At  the  end  of  three 
months  he  recommenced  to  smoke,  and  the  attacks  returned.  He  then  defini- 
tively abandoned  the  use  of  tobacco,  and  the  attacks  of  angina  ceased,  never  to 
return. 

2d.  A  medical  practitioner,  fifty  years  of  age,  feeble  and  dyspeptic,  although 
appearing  healthy  and  robust,  smoked  cigarettes  as  much  as  his  occupations 
would  permit.  During  some  time  he  suffered  from  palpitation  with  severe  pain 
and  constriction  of  the  chest,  which  came  on  indifferently  during  the  day  or 
night.  He  gave  up  tobacco,  and  the  attacks  disappeared.  One  day,  he  was  in 
the  company  of  smokers,  and  although  he  did  not  himself  smoke,  he  could  not 
help  breathing  an  atmosphere  impregnated  with  tobacco.  The  following  night 
he  had  an  attack. 

3d.  A  medical  practitioner  in  the  country,  thirty-five  years  of  age,  was  in  the 
constant  habit  of  smoking  cigarettes  while  going  about  to  pay  visits.  For  some 
time  he  had  eaten  very  little,  and  without  appetite.  One  morning,  having  eaten 
nothing,  and  while  smoking,  he  was  suddenly  seized  with  severe  pain  in  the 
region  of  the  heart,  with  a  sense  of  constriction  in  the  upper  part  of  the  chest. 
He  could  neither  walk  nor  speak,  the  pulse  was  imperceptible,  the  hands  cold. 
The  attack  lasted  half  an  hour.  The  patient  came  to  Paris  and  consulted  Dr. 
Beau,  by  whose  advice  he  gave  up  the  use  of  tobacco.  He  returned  home, 
promising  to  write  to  Dr.  Beau  if  he  had  another  attack.  Nothing  has  since 
been  heard  of  him. 

4th.  A  young  Spaniard,  thirty  years  of  age,  was  constantly  smoking  cigar- 
ettes. His  appetite  entirely  failed,  and  digestion  was  difficult.  One  evening, 
while  smoking,  he  was  suddenly  seized  with  a  violent  pain  in  the  chest,  as  if  he 
had  been  squeezed  in  a  vice ;  his  pulse  was  imperceptible.  The  attack  lasted 
ten  minutes.  Much  alarmed,  he  consented  to  smoke  a  great  deal  less,  and  there 
has  been  no  return  of  the  symptoms  of  angina. 

5th.  A  physician  who  has  renounced  tobacco  on  account  of  the  gastric  de- 


1863.]         Medical  Pathology  and  Therapeutics. 


20.7 


rangement  which  he  suffered  from,  experienced  at  the  time  when  he  was  a 
smoker  nocturnal  pains  coming  on  in  paroxysms,  and  characterized  by  a  con- 
striction of  the  thorax  with  palpitations,  and  neuralgic  pains  shooting  into  the 
neck.    He  is  now  completely  free  from  these  seizures. 

6th.  A  merchant,  who  for  fifteen  or  twenty  years  had  suffered  from  dyspepsia, 
occasioned  by  the  immoderate  use  of  tobacco,  has  suffered  for  about  two  months 
from  nocturnal  attacks,  characterized  by  agonizing  pain  in  the  region  of  the 
heart,  with  palpitations,  and  painful  radiations  extending  to  both  shoulders  ; 
the  appearance  of  the  face  is  altered,  the  pulse  is  small  and  intermittent.  In 
spite  of  the  existence  of  these  symptoms,  this  person  smokes  more  than  ever. 

7th.  An  old  man  of  seventy-five,  fresh  and  vigorous,  smoked  a  great  deal  in 
order  to  distract  his  mind  from  various  sources  of  annoyance,  although  he  had 
had  several  slight  suffocative  paroxysms.  On  a  Saturday,  he  had  an  attak  of 
angina,  which  lasted  for  half  an  hour ;  next  day,  the  attack  recurred ;  on  Mon- 
day morning,  he  was  found  dead  in  bed. 

8th.  A  foreign  diplomatist  who  smoked  a  great  deal,  and  who  was  in  a  feeble 
condition  although  he  appeared  robust,  was  seized  one  evening  in  returning 
home  with  an  attack  of  angina ;  his  pulse  was  small,  his  hands  cold,  his  appear- 
ance choleraic.  He  fell  asleep  at  eleven  o'clock,  and  awoke  next  morning  at 
his  usual  hour.  He  was  able  to  go  through  all  his  ordinary  duties,  and  at  five 
o'clock  in  the  afternoon  was  seated  smoking  in  his  arm-chair,  when  he  suddenly 
expired.  On  post-mortem  examination  the  only  lesion  found  was  a  fatty  con- 
dition of  the  heart. — Ed.  Med.  Journ.  Aug.,  1862,  from  Journ.  de  M6d.  et  de 
Chirurg.  pract.,  July,  1862. 

22.  Rheumatic  Pericarditis  and  Endocarditis. — Dr.  Joseph  Bell,  Clinical 
Lecturer,  Glasgow  Eoyal  Infirmary,  has  published  (Glasgoiv  Medical  Journ., 
April  and  July,  1862)  some  interesting  practical  remarks  on  the  diagnosis  and 
treatment  of  rheumatic  pericarditis  and  endocarditis. 

From  the  facts  and  reasonings  adduced  in  that  paper  he  makes  the  following 
conclusions : — 

1st.  That  when  the  physical  symptoms  either  of  pericarditis  or  endocarditis 
become  manifested  in  a  case  of  rheumatic  fever,  we  are  entitled  to  infer  that 
these  diseases  exist,  irrespective  of  the  absence  of  the  general  or  constitutional 
symptoms  which  usually  attend  the  idiopathic  forms  of  these  diseases. 

2d.  That  we  are  justified  in  considering  that  the  effects  are  capable  of  being 
removed,  and  are  therefore  amenable  to  treatment. 

3d.  That  those  remedies  which  are  calculated  to  remove  congestion  and  pro- 
mote absorption,  form  the  proper  therapeutic  agents  ;  and  that  of  these  bleed- 
ing, mercury,  and  iodide  of  potassium,  are  among  the  most  powerful  and  useful. 

4th.  That  when  the  action  of  the  heart  becomes  enfeebled  in  consequence  of 
effusion  into  the  pericardium,  the  free  use  of  stimulants  becomes  absolutely 
necessary. 

23.  The  Physiology  and  Pathology  of  the  Supra-renal  Capsides. — The  fol- 
lowing are  the  conclusions  arrived  at  by  Dr.  Harley  in  his  prize  essay  on  this 
subject :  1.  The  supra-renal  capsules  are  not  fcetal  organs,  but  perform  their 
functions  up  to  the  latest  periods  of  life.  2.  The  supra-renal  capsules  are  not 
absolutely  essential  to  life.  When  removed  artificially  or  destroyed  by  disease, 
their  function  is  vicariously  performed  by  the  other  "ductless  glands,"  more 
especially  by  the  thymus.  3.  Young  animals  support  the  removal  of  the  supra- 
renal capsules  better  than  old  ones  (probably  on  account  of  the  greater  activity 
of  the  thymus  in  early  life).  4.  When  only  one  capsule  is  extirpated,  the  other 
performs  the  double  function.  5.  A  wounded  capsule  heals  readily.  6.  The 
supra-renal  capsules  are  not  marked  by  any  great  sensibility.  7.  The  removal 
of  the  right  is  more  frequently  attended  with  fatal  results  than  removal  of  the 
left  supra-renal  capsule.  8.  The  lower  animals  are  liable  to  disease  of  the  supra- 
renal capsules.  9.  When  death  follows  upon  the  extirpation  of  the  supra-renal 
capsules,  in  the  majority  of  cases  it  is  in  consequence  of  the  injury  done  to  the 
solar  plexus.  10.  The  supra-renal  capsules  are  richly  supplied  by  bloodvessels 
as  well  as  by  nerves.  11.  Their  function  is  apparently  intimately  connected 
with  the  formation  of  the  red  blood  corpuscles. 


208 


Progress  of  the  Medical  Sciences. 


[Jan. 


The  author  further  shows,  from  a  large  collection  of  facts,  that — 
1st.  Supra-renal  capsular  disease  is  two  times  and  a  half  more  frequent  in 
males  than  in  females. 

2d.  That  it  occurs  with  equal  frequency  above  and  below  the  age  of  thirty- 
five  years. 

3d.  That  both  capsules  are  (four  times)  more  liable  to  be  affected  than  only 
one. 

4th.  That  the  right  capsule  is  much  more  liable  (three  times)  to  become  dis- 
eased than  the  left. 

5th.  In  diseased  supra-renal  capsules — 

40  per  cent,  are  affected  with  tubercle. 
20      "  "  "  cancer. 

12      "  "  "       fatty  deposit. 

12      "  "  "       calcareous  deposit. 

6th.  Males  are  more  liable  to  be  affected  with  bronzed  skin  (either  with  or 
without  supra-renal  capsular  disease)  than  females,  the  proportion  being  as  3 
to  l.—Lond.  Med.  Bev.,Oct.  1862. 

24.  Morbus  Addisonii. — Dr.  Wilks  exhibited  to  the  London  Pathological 
Society  the  supra-renal  capsule  from  a  patient  who  had  died  of  morbus  Addi- 
sonii. The  specimen  had  been  sent  to  Dr.  ~W.  by.  Mr.  Truman,  of  the  Notting- 
ham Dispensary,  the  patient  having  been  under  the  care  of  Mr.  Marshall  Hall 
Higginbottom.  When  first  seen  he  was  26  years  of  age,  complained  of  exces- 
sive weakness  and  want  of  energy,  and  there  was  a  slight  yellowish  tinge  on  his 
countenance.  He  gradually  lost  flesh  and  strength  until  he  became  confined  to 
his  bed ;  he  then  underwent  a  thorough  examination,  and  no  disease  could  be 
found  in  his  body.  The  skin  gradually  darkened,  and  the  only  thing  he  ever 
complained  of  was  an  aching,  dull  pain  in  the  loins.  The  weakness  increased, 
and  towards  the  close  there  was  vomiting.  On  post-mortem  examination,  the 
skin  was  observed  to  be  universally  discoloured,  of  a  yellowish-brown  hue,  and 
more  markedly  so  on  the  abdomen ;  but  there  were  no  distinct  patches  of 
melasma.  All  the  organs  were  healthy  with  the  exception  of  the  supra-renal 
capsules ;  these  were  twice  the  natural  size,  and,  on  section,  seemed  to  be 
densely  infiltrated  with  masses  of  yellow  tubercle. — Med.  Times  and  Gaz.,  Oct. 
25,  1862. 

25.  Bronzed  Skin  Successfully  Treated. — Thos.  Taylor,  Esq.,  of  Cricklade, 
relates  (British  Medical  Journal,  March  29, 1862)  the  following  case  :  "  On  the 
27th  of  June,  1861,  I  was  called  upon  to  visit  Isaac  Matthews,  a  carpenter  by 
trade,  stoutly  made,  of  sanguine  temperament,  and  about  36  years  of  age.  I 
found  he  had  been  unwell  for  some  time,  and  had  been  obliged  to  leave  his  work 
the  last  fortnight,  simply  from  weakness.  He  was  unable  to  walk  across  the 
room  without  assistance  ;  he  was  in  no  pain,  but  felt  an  uneasiness  about  the 
loins ;  his  appetite  was  not  good ;  the  bowels  were  regular,  and  the  secretions 
from  the  bowels  and  kidneys  healthy.  The  skin  of  the  face  and  hands  was  highly 
bronzed,  and  had  become  so  about  the  time  he  left  his  work  :  he  said  his  friends 
had  remarked  of  what  a  curious  colour  he  was.  He  was  advised  to  keep  per- 
fectly quiet,  and  do  nothing  whatever  to  produce  fatigue,  by  attempting  to  walk 
or  otherwise  ;  to  take  sugar  in  large  quantities  with  everything  he  drank ;  and 
to  take  five  grains  of  iodide  of  potassium  three  times  a  day,  in  water. 

"July  1st.  He  was  much  the  same.  He  did  not  find  the  medicine  to  disagree 
in  any  way,  and  was  ordered  to  continue  the  same. 

"July  5th.  He  felt  better  before  he  was  up  this  morning,  and  thought  he 
should  be  able  to  walk  ;  but  on  getting  up  felt  as  weak  as  ever.  He  was  ordered 
to  continue  the  iodide  of  potassium  three  times  a  day  in  four  ounces  of  compound 
decoction  of  sarsaparilla. 

"  July  12th.  He  was  rather  stronger,  and  walked  rather  better ;  the  com- 
plexion was  rather  improved.  He  continued  to  mend  under  this  treatment  until 
the  22d,  when  he  had  a  severe  rigor,  which  returned  the  next  and  following  day, 
succeeded  by  fever,  which  reduced  his  strength. 


1863.]  Medical  Pathology  and  Therapeutics. 


209 


"  On  the  24th  he  had  five  grains  of  disulphate  of  quina,  twice  a  day,  with  croton 
oil  liniment  to  the  loins. 

"  On  the  7th  of  August  his  febrile  state  had  left  him,  but  was  succeeded  by  a 
bronchial  cough  which  was  relieved  in  a  few  days ;  so  that  on  the  9th  he  began 
taking  the  syrup  of  iodide  of  iron  in  half-drachm  doses  three  times  a  day,  con- 
tinuing to  take  sugar  in  large  quantities.  Under  this  treatment  he  went  on 
improving  daily;  his  complexion  became  of  its  natural  colour;  his  strength 
increased,  so  that  he  was  enabled  to  walk  a  mile  with  the  assistance  of  a  walking 
stick,  by  the  19th;  and  by  the  end  of  the  month  he  walked  to  Oicklade,  a  dis- 
tance of  nearly  five  miles. 

"  On  the  9th  of  September  he  again  walked  to  Cricklade,  and  appeared  quite 
to  have  recovered  his  health  and  strength,  and  the  next  day  resumed  his  worl#. 

"I  heard  nothing  of  him  again  until  the  5th  of  February  last,  when  I  was 
requested  to  visit  him,  as  it  was  thought  he  had  a  return  of  his  complaint.  On 
seeing  him,  however,  I  was  happy  to  find  that  he  was  suffering  from  an  attack 
of  rheumatism,  having  got  wet  away  from  home  three  times  the  week  before, 
and  being  unable  to  change  his  clothes.  This  yielded  very  readily  to  treatment 
in  a  few  days,  when  he  resumed  his  work,  and  has  continued  well  to  the  present 
time." 

26.  Diabetes  Mellitus  ending  in  Phthisis. — Dr.  Willett  exhibited  to  the 
county  and  city  of  Cork  Med.  and  Surg.  Soc.  (April  9,  1862),  the  kidneys  and 
lungs  of  a  patient,  and  related  the  history  of  the  case  : — 

'•  The  following  case,  which  Dr.  Townsend  has  kindly  allowed  me  to  bring- 
under  your  notice,  is  a  case  of  diabetes  mellitus  ending  in  phthisis,  as  is  com- 
monly the  case  with  this  incurable  disease  : — ■ 

"  Michael  Murphy,  aged  24  years,  was  admitted  into  the  Workhouse  Hospital 
on  January  21,  1860.  At  that  time  he  was  passing  about  three  pints  of  sac- 
charine urine  per  diem,  with  a  specific  gravity  of  1025,  to  1030.  During  twelve 
months  from  this  time,  he  passed  from  8  to  12  pints  of  the  same  urine  per  diem, 
the  mean  specific  gravity  ranging  from  1035  to  1040.  He  was  placed  under  the 
usual  treatment  for  this  disease,  viz.,  brown  bread  and  oleum  jecoris  aselli,  and 
during  its  continuance  regained  health  and  strength  in  some  measure;  but,  as 
soon  as  discontinued,  viz.,  the  brown  bread,  the  sugar  again  appeared  in  the  urine, 
and,  after  a  severe  struggle  with  himself,  the  poor  fellow  gave  up  the  brown  bread 
from  intense  disgust,  and  was  allowed  his  usual  meals.  The  disease  from  this 
time,  August  20,  1861,  gradually  decreased,  the  sugar  daily  diminishing,  as  if 
the  disease  had  exhausted  itself.  But  now  as  incurable  a  one  set  in,  viz.,  phthisis,, 
with  its  evident  signs  of  night  perspirations,  cough,  hectic,  &c.  This  has  gra- 
dually increased  up  to  the  present  time.  About  two  months  ago,  he  coughed 
up  purulent  matter,  streaked  with  blood,  in  large  quantities,  but  with  very  little 
fetor  attending  it.  He  then  became  excessively  weak  and  anemic,  suffered 
greatly  from  dyspnoea,  so  that,  during  the  last  month  of  his  life,  he  was  sup- 
ported by  pillows  at  his  back,  night  and  day ;  the  congested  state  of  one  lung, 
the  right,  and  the  emphysematous  condition  of  the  left,  fully  explain  this,  and 
he  gradually  sank  till  April  17,  1862,  eased  his  sufferings. 

"Post-mortem  appearances. — The  body  excessively  emaciated,  not  a  trace  of 
adipose  tissue  being  visible  under  the  skin,  and  the  muscles  of  a  bluish  colour, 
their  normal  red  colour  being  entirely  lost.  The  lungs  extensively  disorganized, 
that  on  the  right  side  completely  bound  down  to  the  pleura  and  ribs,  by  very 
strong  adhesions,  which,  at  the  apex,  I  could  not  separate  by  my  fingers,  but 
was  obliged  to  cut,  as  you  see  by  specimen  ;  it  is  quite  solid,  as  also  is  the  entire 
of  this  lung.  Either  from  tubercle,  or  its  irritative  effect,  on  cutting  it  open  an 
immense  amount  of  pus  escaped,  which  I  traced  to  a  large  vomica  or  abscess  at 
the  apex,  and  I  also  found  a  similar  one  in  the  middle  of  the  same  lung.  I  also 
beg  you  to  observe  the  intense  state  of  suppuration  it  is  in,  nearly  approaching 
to  the  third  stage  of  pneumonia,  by  Laennec  called  gray  hepatization ;  or  gray 
softening,  by  Andral,  having  both  within  and  externally  a  yellowish  or  grayish 
colour,  and  when  cut,  exuding  a  yellow,  opaque,  purulent  fluid,  turgid  somewhat 
with  blood  ;  that  on  the  left  side  emphysematous.  If  you  observe  at  the  borders, 
on  squeezing  it,  you  will  perceive  the  course  of  several  small  bloodvessels,  not  yet 
No.  LXXXIX.— Jan.  1863.  14 


210 


Progress  of  the  Medical  Sciences.  [Jan. 


obliterated  by  the  enlarged  air-cells,  showing  that  the  emphysema  was  in  this 
case  recent.  The  heart  was  small,  from  the  reason  of  the  little  amount  of  blood 
to  drive  through  the  body  for  its  nutrition,  and  also  of  a  pale  colour.  Liver 
normal,  but  rather  enlarged.  Stomach  normal  on  the  outside ;  on  being  cut 
open,  full  of  thick  gastric  juice,  very  acid.  Kidneys,  as  here  seen,  not  much 
enlarged,  and  only  in  a  very  hyperaemic  state.  Structure  tolerably  distinct,  and 
showing  how  very  evanescent  are  the  traces  of  this  formidable  disease. 

"In  regarding  the  prognosis  of  this  disease,  I  think  that  we  can  never  look  for  a 
successful  cure,  as,  should  the  saccharine  state  of  the  urine  cease,  or  the  diabetes 
be  cured,  the  general  tendency  is,  as  asserted  by  several  authors,  to  pass  either 
into  phthisis  or  morbus  Brightii.  The  tendency  to  phthisis  we  can  easily  imagine, 
in  consequence  of  the  tissues  of  the  lungs  being  so  poorly  nourished,  and  its 
tendency  thus  to  degenerate  into  tubercle,  and  this  particularly  so  should  the 
patient  show  any  tendency  to  the  strumous  diathesis  ;  its  leading  to  subsequent 
atrophy  of  the  kidneys  also  we  may  assume,  in  consequence  of  their  hyperaemic 
state,  which  is  the  first  stage  of  B  right's  disease,  in  consequence  of  their  over- 
increased  function,  this  hyperaemic  state  soon  leading  to  obstruction  of  the  renal 
tubuli  by  fibrin,  the  pressure  of  this  on  the  small  capillaries  tending  to  exudation 
of  the  albuminous  portion  of  the  blood  as  well  as  the  increased  action  of  the 
epithelial  cells  in  the  tubuli,  which,  with  the  pressure  of  the  enlarged  capillaries 
on  their  outside  and  loss  of  cells  by  desquamation,  and  entirely  filling  up  the 
secreting  portion,  soon  passes  into  fatty  degeneration,  or  the  small,  contracted, 
or  atrophied  kidney.  I  think  it  is  also  very  difficult  to  state  whether  the  sup- 
purative condition,  or  abscesses  in  the  lungs  in  this  case,  arises  from  tubercle 
or  chronic  pneumonia,  as,  on  feeling  very  carefully  over  both  lungs,  I  could 
not  trace  a  single  hard  substance  between  my  fingers.  We  rarely  see  it  so  en- 
tirely consolidated  with  tubercle  excepting  in  cases  of  tuberculous  infiltration. 
But,  if  we  argue  that  such  is  the  case,  how  do  we  account  for  the  entire  mass  of 
tubercles  suppurating  en  masse,  at  the  same  time  as  to  the  tendency  of  tubercle 
to  the  upper  part  and  pneumonia  to  the  lower  lobes,  as  well  as  to  the  arguments 
deduced  for  the  preferable  localities  of  each  on  the  right  or  left  sides.  I  find  the 
best  authors  differing,  and,  on  that  account,  deduce  that  we  may  consider  the 
question  as  yet  sub  judice.  I  find  that,  after  searching  several  books,  it  agrees 
with  a  form  of  pneumonia  called  chronic.  Under  this  head  I  find  that  abscesses 
are  frequently  found ;  also,  in  another  form  of  the  same,  the  lung  is  found  com- 
pact, and  heavy,  pitting  little  or  none  on  pressure,  not  crepitant,  tearing  with 
difficulty,  sometimes  almost  cartilaginous ;  when  cut,  exuding  a  purulent  or 
muco-purulent  fluid ;  the  colour  dull  red,  or  yellowish-brown  or  grayish.  When 
distinct  lobules  are  affected,  the  lung  has  an  irregular,  knotty  feel ;  its  volume 
is  diminished  sometimes.  Abscesses  exist  within  the  hardened  structure,  and, 
in  some  instances  gangrene  was  observed  by  Andral." — Dublin  Quart.  Journ. 
Med.  Sc.,  Nov.  1862. 

27.  New  Means  of  Distinguishing  Diabetic  Urine. — M.  Paillon,  of  Sainte- 
Foy-lez-Lyon,  has  observed  that  diabetic  urine,  if  allowed  to  stand  for  ever  so 
long  a  time  exposed  to  the  air,  does  not,  like  ordinary  urine,  emit  any  smell  of 
decomposition.  A  specimen  which  had  been  exposed  to  the  air  during  a  fort- 
night had  only  become  somewhat  lighter  coloured  and  a  little  muddy,  but  gave 
out  no  nauseous  odour.  This  urine  was  submitted  to  M.  Burin  du  Buisson  for 
analysis,  and  he  failed  to  discover  any  sugar ;  but,  on  being  told  of  the  length  of 
time  which  had  elapsed  since  the  urine  was  passed,  he  examined  it  again,  and 
readily  discovered  alcohol,  into  which  the  sugar  had  become  transformed.  M. 
Paillon  suggests  that  the  absence  of  odour  after  long  exposure  to  air  would  form 
a  useful  test  of  the  presence  of  sugar  in  urine  in  cases  where  the  physician  might 
not  have  chemical  reagents  at  hand. — London  Med.  Rev.,  Aug.  1862,  from 
Gazette  des  Hopitaux,  3  Juillet. 

28.  Production  of  Carbonate  of  Ammonia  in  the  Blood  in  Urosmic  Poison- 
ing.— Dr.  Alex.  Petroff,  of  Dorpat,  has  published  some  very  important  re- 
Bearches,  which  go  to  support  the  theory  of  Frerichs.  The  object  of  these 
investigations  was  chiefly  to  examine  the  validity  of  Oppler's  statements 


1863.] 


Medical  Pathology  and  Therapeutics. 


211 


founded  on  experiments  of  his  own,  in  opposition  to  Frerichs.  Oppler  stated 
that  Frerichs'  second  and  third  inductions  were  incorrect,  and  that  the  theory 
based  on  them  was  therefore  groundless.  He  declared  that  after  artificially 
producing  uraemia  in  animals  (by  removal  of  the  kidneys  or  ligature  of  the 
ureters),  he  was  unable  to  detect  carbonate  of  ammonia  in  the  blood  or  secre- 
tions ;  and,  moreover,  that  the  injection  of  carbonate  of  ammonia  into  the  venous 
system  of  animals  fails  to  produce  any  symptoms  truly  comparable  to  those  of 
uraemia.  He  declared  that  in  uraemia,  as  Hoppe  had  long  since  stated,  the 
quantity  "of  urea  and  extractives  in  the  blood,  and  the  quantity  of  extractive  in 
the  muscles,  was  abnormally  increased.  Dr.  PetrofF's  present  investigations 
were  made  with  the  sanction  and  assistance  of  Professors  Bidder  and  Schmidt. 
Dogs  and  cats  were  chloroformized,  and  the  operation  of  nepheotomy  carefully 
performed.  After  recovery  from  the  chloroform,  the  jugular  vein  was  opened, 
at  various  distances  of  time  from  the  operation,  and  the  blood  received  into  two 
vessels  each  containing  absolute  alcohol.  One  of  these  portions  of  blood  was 
to  be  tested  for  urea,  a  few  drops  of  acetic  acid  were  added  to  this,  and  the  mass 
allowed  to  stand  for  twenty-four  hours  in  a  cold  place,  filtered,  and  the  filtrate 
evaporated  to  a  dry  mass,  which  was  repeatedly  washed  with  water  and  with 
absolute  alcohol,  and  then  set  aside  to  crystallize  over  sulphuric  acid.  Pris- 
matic needles  of  urea  were  thus  obtained,  and  the  presence  of  urea  was  confirmed 
by  other  tests.  The  other  portion  of  blood,  examined  for  carbonate  of  ammonia, 
was  received  also  into  absolute  alcohol  and  then  at  once  distilled,  the  distillate 
being  received  into  dilute  hydrochloric  or  sulphuric  acid  of  known  strength. 
The  quantity  of  free  ammonia  was  thus  decided  :  while  the  ammonia  in  combi- 
nation was  estimated  by  the  examination  of  the  residue  left  from  the  distillation. 
The  bile,  the  contents  of  the  stomach,  and  other  fluids  of  the  body,  were  also 
examined  for  ammonia.  Dr.  Petroff  also  made  a  series  of  very  careful  experi- 
ments on  the  comparative  effects  of  injections  of  ammonia  into  the  blood,  and 
the  artificial  production  of  uraemia.  The  following  are  the  general  conclusions 
at  which  he  arrives  :  1.  When  the  kidney  function  is  interrupted,  carbonate  of 
ammonia  is  formed  in  the  blood.  2.  Injection  of  carbonate  of  ammonia  into  the 
blood  produces  symptoms  strictly  comparable  to  those  of  uraemia.  3.  The 
degree  in  which  these  symptoms  appear,  and  their  character,  depends  on  the 
proportion  of  ammonia  in  the  blood,  and  the  circumstances  in  which  it  exists 
there. — London  Med,  Rev.,  Nov.  1862,  from  Virchow's  Archiv. 

29.  Membranous  Cysts  in  the  Interior  of  the  Urinary  Bladder. — Dr.  E.  Knox 
states  (Med.  Times  and  Gaz.,  Aug.  2,  1862)  that  his  attention  was  drawn,  a 
short  time  since,  to  this  subject  by  a  deplorable  case,  of  which  some  account 
was  given  in  the  medical  journals.  From  what  appeared  in  the  brief  narrative, 
the  nature  of  the  case  did  not  seem  clear.  A  lady,  during  her  confinement, 
suffered  severely  from  retention  of  urine,  and  although,  subsequently  relieved, 
at  last  sunk,  in  consequence,  seemingly,  of  the  sufferings  caused  by  the  retention. 
A  post-mortem,  made  by  Mr.  Spencer  Wells,  disclosed  a  condition  of  the  urinary 
bladder  such  as  was  to  be  expected  from  an  intense  inflammation  of  the  mucous 
membrane  of  the  viscus.  A  sac,  seemingly  composed  of  the  mucous  membrane 
itself,  lay  coiled  up  in  the  interior  of  the  bladder.  It  was  also  surmised  that 
vascular  fibres  might  be  seen  on  one  surface  of  this  sac,  so  that  during  the  pro- 
gress of  the  disease,  according  to  this  view  of  the  case,  two  layers  of  the  walls 
of  the  urinary  bladder  had  sloughed  and  lost  all  connection  with  the  remaining 
walls  of  the  organ. 

This  view  of  the  case  seemed  to  Dr.  K.  to  be  untenable,  and  he  felt  disposed 
"  rather  to  think  that  the  cyst  or  detached  membrane  in  question  could  be  nothing 
more  than  a  pseudo-membranous  bag,  formed  in  the  usual  way  by  an  inflamed 
mucous  surface,  as  we  find  so  frequently  in  cases  of  croup,  etc.  Happening 
shortly  thereafter  to  meet  Dr.  Tanner,  I  discussed  the  matter  with  him,  and 
narrated  to  him  the  following  remarkable  case,  which  occurred  in  the  practice 
of  Mr.  Liston,  and  of  which  I  was  not  only  an  eye-witness,  but  acted  throughout 
as  his  assistant. 

"Late  one  evening  Mr.  Liston  called  on  me  and  asked  me  to  accompany  him 
and  to  assist  him  in  an  operation  he  contemplated,  and  in  order  not  to  lose  time 


212  Progress  of  the  Medical  Sciences.  [Jan. 


he  would  narrate  the  particulars  as  we  walked  along.  They  were  as  follow  : 
The  patient  was  a  man  in  humble  life ;  he  had  been  unwell  for  some  time,  com- 
plaining chiefly  of  an  obstruction  to,  or  a  difficulty  in  discharging  the  urine 
from  the  bladder.  On  passing  a  catheter,  Mr.  Liston  felt,  or  fancied  he  felt  a 
soft,  yielding,  but  obstructing  body  in  the  prostatic  portion  of  the  urethra. 
This  readily  gave  way  before  the  catheter,  which  then  passed  into  the  bladder, 
but  on  being  withdrawn  it  was  followed  by  the  foreign  body,  which  immediately 
reoccupied  its  former  position.  Mr.  Liston  then  explained  to  me  his  view  of  the 
case,  which  was  this:  'A  cyst  or  false  membrane  of  the  form  of  the  bladder 
itself,  occupied,  as  he  conjectured,  the  interior  of  the  bladder,  and  were  this 
removed  by  an  operation  the  patient  might  recover.'  The  boldness  of  the  proposal, 
or  rather  the  diagnosis  itself,  astonished  me,  and  I  told  him  so;  but  on  intro- 
ducing the  catheter,  and  meeting  with  the  same  phenomena  as  he  had  described, 
I  at  once  gave  into  his  view.  We  were  alone.  With  a  straight  sharp-pointed 
bistoury,  which  he  usually  carried  in  his  waistcoat  pocket,  he  opened  the  bladder 
above  the  pubes,  and  as  the  incision  proceeded  there  escaped  from  the  bladder 
a  foreign  body  resembling  a  cyst  or  false  membrane,  as  he  and  I  concluded  it  to 
be.  and  of  the  shape  of  the  interior  of  the  bladder.  It  escaped  into  my  hands. 
The  wound  was  closed  simply ;  and  as  we  returned  home,  bringing  the  prepara- 
tion with  us,  I  could  not  but  observe  to  him  that  of  all  the  bold  and  successful 
operations  he  had  performed,  none  equalled  in  merit  the  diagnosis  he  had  just 
made,  and  that  half  a  century  might  elapse  before  he  made  such  another.  The 
patient  recovered  and  lived  for  some  time. 

"  From  that  day  until  the  present  time  I  heard  no  more  of  the  case,  and  thought 
no  more  of  it  until  the  occurrence  of  the  one  mentioned  by  Mr.  Spencer  Wells 
to  the  Pathological  Society.  Discussing  it  with  Dr.  Tanner,  I  .  suggested  that 
we  should  look  for  Mr.  Liston's  preparation  in  the  museum  of  the  College  of 
Surgeons,  to  which  museum  I  knew  that  Mr.  Liston  had  presented  a  few  rare 
pathological  specimens  he  had  brought  with  him,  many  years  ago,  to  London. 
To  my  surprise,  we  found  a  layer  of  muscular  fibres  on  the  cyst,  thus  throwing 
doubts  over  the  nature  of  the  preparation  itself.  There  was  the  identical  cyst, 
or  pseudo-membrane  as  I  had  always  fancied  it  to  be,  evidently  complicated  with 
another  structure,  whose  presence  there  could  not  be  readily  explained  on  the 
pathology  of  Baillie  or  Hunter.  I  have  again  re-examined  the  preparation  with 
Mr.  Henry  Thomson,  whose  great  experience  and  extended  inquiries  into  pros- 
tatical  and  vesical  diseases  are  well  known.  I  think  that  the  presence  of  mus- 
cular fibres  forming  a  sort  of  layer  of  the  sac,  cannot  well  be  doubted,  so  that 
the  preparation  is  not  altogether  what  Mr.  Liston  and  I  took  it  to  be — a  simple 
pseudo-membrane  composed  of  but  one  tissue;  and  now  arose  the  question  in 
my  mind,  whether  I  had  not  seen  or  read  somewhere  of  the  formation  of  false 
muscular  fibres,  the  product  of  inflammation,  as  well  as  of  the  usual  pseudo- 
membrane,  for  I  felt  disinclined  to  believe  in  the  theory  that  the  cyst  found  in 
the  bladder  was  in  reality  the  mucous  membrane,  and  a  layer  of  the  muscular, 
in  a  sloughing  state  detached  from  the  walls  of  the  cavity.  1  felt  convinced 
that  I  had  read  of  a  case  or  two1  in  which  a  layer  of  muscular  fibres  had  formed 
in  large  masses  of  exudation,  arising  from  an  inflammation  of  fibrous  or  cellular 
membrane.  Turning  to  the  learned  Yogel,  I  there  found  the  title  of  the  work, 
'Tractatus  Anatomico  Pathologicus  Sistens  duas  Observationes  rarissimas  de 
Formatione  Fibrarum  Muscularum  in  pericardio  Atque  in  pleura  obviarum.' 
Leo-Wolf:  Heidelberg  et  Leips.  1832.  Vogel  quotes  Wutzer's  critique  on  it  in 
Mailer's  Archiv.,  1834,  p.  45.  I  never  saw  Leo-Wolf's  preparation,  but  if  the 
engravings  in  his  treatise  truly  represented  the  structures,  then  undoubtedly 
muscular  fibres  had  been  formed  by  the  same  process  which  gave  rise  to  the 
effused  false  membrane  on  which  they  rested.  But  Yogel,  whose  accuracy  is 
extreme  in  all  such  matters,  assures  us  (p.  184)  that  'the  microscopic  examina- 
tion (the  only  decisive  test)  had  been  altogether  neglected,  as  in  the  cases  ob- 
served by  Leo-Wolf.'  But  simple  non-striated  fibres  are  often  formed  as  inde- 
pendent (fibroid)  tumours,  and  causing  hypertrophy  of  the  muscular  walls  of 
cavities.    The  question  then  is,  what  is  the  real  nature  of  the  seemingly  muscu- 


1  The  treatise  was  at  one  time  in  my  own  library,  but  has  been  lost. 


1863.]  Medical  Pathology  and  Therapeutics. 


213 


lar  fibres  to  be  distinctly  seen  in  the  cyst  removed  from  the  urinary  bladder  by 
Mr.  Liston?  Of  those  somewhat  more  doubtful  in  the  first  casHdiscussed  by 
Mr.  Spencer  Wells,  in  his  second  case,  and  in  the  very  interesting  case  of  Mr. 
Maunder,  which  he  kindly  related  to  me,  and  which  I  am  indebted  to  Mr.  Henry 
Thomson  for  an  opportunity  of  examining  with  the  utmost  attention,  assisted 
with  all  his  knowledge  of  these  structures.  A  brief  statement  of  the  history 
of  these  cases  may  ultimately  lead  to  some  important  investigations,  and  clear 
up  a  pathological  question  of  the  obscurest.  For  my  own  part,  I  feel  disposed 
to  reduce  the  whole  phenomena  to  one  simple  law  of  morbid  epigenesis  of  mus- 
cular fibres,  real  or  apparent." 

30.  Inversion  of  the  Urinary  Bladder  through  the  Urethra,  with  large  Pro- 
lapsus of  the  Rectum.,  in  a  Female  Child. — Dr.  Beatty  communicated  to  the 
Dublin  Pathological  Society  an  example  of  this.  The  subject  of  it  was  a  female 
child,  aged  one  year  and  eleven  months,  which  was  sent  from  the  country  to  the 
City  of  Dublin  Hospital,  with  a  statement  that  there  was  something  wrong  with 
the  genital  and  urinary  organs.  She  was  a  fine,  strong,  handsome  child.  The 
appearance  of  the  parts  was  most  extraordinary.  Just  between  the  labia  there 
was  a  scarlet  tumour  about  the  size  of  a  chestnut ;  and  it  at  once  struck  him 
that  it  was  the  inner  surface  of  the  bladder,  similar  to  what  has  been  seen  in 
cases  of  vesico-vaginal  fistula,  or  of  malformation  where  the  anterior  wall  of  the 
abdomen  is  open  above  the  pubes,  and  the  inner  coat  of  the  bladder  protrudes. 

Upon  touching  it  with  his  finger  the  child  cried  violently.  It  could  be  forced 
back,  and  even  replaced  by  pressure  ;  and  the  urethra  was  sufficiently  large  to 
admit  of  the  easy  passage  of  his  forefinger  into  the  replaced  bladder,  showing 
the  case  to  be  one  of  complete  inversion  of  the  bladder  through  the  urethra. 
The  mother  told  him  that  the  inversion  of  the  bladder  did  not  take  place  until 
the  child  had  a  fit  of  crying  when  it  was  twelve  months  old.  There  was  also  a 
large  prolapsus  of  the  rectum,  which  occurred  when  she  was  nine  months  old, 
in  consequence  of  an  attack  of  diarrhoea.  The  child  remained  in  hospital  up  to 
Monday  last,  and  continued  quite  well.  Dr.  Beatty  kept  her  in  for  the  purpose 
of  devising  some  means  to  remedy  the  defect.  On  Sunday  morning,  however, 
she  was  attacked  with  severe  croup,  which  terminated  in  her  death  on  Monday 
evening.  He  was  thus  enabled  to  obtain  the  specimen  now  before  the  society, 
showing  the  bladder  turned  inside  out  through  the  urethra.  It  had  now  lost 
some  of  the  scarlet  colour,  and  something  of  its  size.  In  the  prolapsus  of  the 
rectum  there  was  nothing  remarkable ;  but,  combined  with  the  other  defect,  it 
gave  the  parts  a  very  curious  appearance.  The  uterus  was  in  situ,  and  the 
ovaries  weiy  very  large  for  a  child  of  her  age.  Dr.  Beatty  had  never  seen  an- 
other instance  of  such  inversion.  The  child  died  of  croup,  as  he  before  stated, 
and  the  specimen  showed  a  very  perfect,  well-formed  false  membrane,  lining 
the  trachea,  and  forming  a  tube  within  it.  The  gentleman  who  made  the  post- 
mortem examination  told  him  that  the  deposit  of  false  membrane  did  not  extend 
lower  down  than  the  bifurcation  of  the  trachea. — February  22,  1862. — Dublin 
Quart.  Journ.  Med.  Sc.,  Aug.  1862. 

31.  Verruca  Necrogenica. — Dr.  "Wilks  exhibited  to  the  London  Pathological 
Society  (Oct.  21,  1862),  wax  models  of  disease  of  the  hands  produced  by  post- 
mortem examinations.  The  patient,  a  young  man,  had  been  employed  in  the 
post-mortem-room.  The  models  illustrated  the  peculiar  affection  of  the  skin 
produced  by  the  acrid  fluids  of  the  dead  body.  The  knuckles  of  both  hands 
had  upon  them  brown,  circular,  raised  patches  of  morbid  epithelium,  giving  the 
appearance  somewhat  of  epithelial  cancer.  The  chronic  and  obstinate  nature  of 
these  warty  excrescences  was  most  remarkable,  for,  if  removed  or  portions  be 
picked  off,  they  again  grow,  and  remained  for  years.  Dr.  Wilks  had,  on  more  than 
one  occasion,  recognized  this  disease  in  strangers,  and  suggested  its  cause,  for 
which  reason  he  believed  it  to  be  peculiar  and.  characteristic ;  at  least,  he  knew 
of  no  other  irritants  which  produced  exactly  the  same  effect.  There  was  no 
name  already  in  use  which  was  strictly  applicable  to  it,  since  epithelioma,  lepra, 
&c,  were  already  in  use  for  definite  affections  ;  he  had,  therefore,  simply  styled 
it  warty  or  verruca  necrogenica. 


214 


Progress  of  the  Medical  Sciences. 


[Jan. 


Mr.  Spencer  Wells  asked  if  the  disease  was  not  the  same  as  that  known  as 
the  Anatomical  Tubercle  of  Pinel.  He  had  seen  it  in  several  persons,  but  had 
only  once  observed  it  in  any  one  out  of  the  profession.  This  was  in  a  clergy- 
man who  was  fond  of  bird-stuffing. 

Dr.  Bristowe  said  that  he  had  had  it  two  years,  and  had  watched  it  closely. 
At  first  it  was  a  small  pustule,  which  was  covered  by  a  scab,  consisting  of  epi- 
thelium with  little  conical  processes.  It  never  contained  any  nested  cells.  At 
first  he  applied  to  it  mild  caustics,  as  nitrate  of  silver,  but  these  only  made  it 
more  irritable.  He,  therefore,  destroyed  it  by  one  free  application  of  the  acid 
nitrate  of  mercury. 

Dr.  Peacock  said  that  when  in  Edinburgh  he  was  troubled  with  a  similar 
affection.  He  agreed  with  Dr.  Bristowe  that  mild  caustics  only  made  matters 
worse.  After  a  few  years  it  disappeared.  At  the  first  he  had  several  boils,  but 
one  of  them  never  sloughed,  and  went  on  to  the  state  mentioned. 

Dr.  Harley  said  that  last  year  he  was  consulted  by  a  man  whose  duty  it  had 
been  for  many  years  to  assist  in  making  post-mortem  examinations  at  University 
College  Hospital.  At  the  time  when  he  saw  him,  however,  he  was  acting  as 
porter.  The  hands  were  covered  by  tubercles.  On  scraping  them  and  putting 
the  scrapings  under  the  microscope,  he  found  great  hypertrophy  of  the  epi- 
dermis. He  did  not  think  that  the  disease  extended  to  the  true  skin.  He 
advised  the  application  of  nitrate  of  silver,  and  this  was  followed  by  some 
benefit  during  its  use. 

Dr.  Wilks  said  that  he  supposed  all  were  agreed  as  to  its  pathology — that  it 
was  an  affection  of  the  epidermis  only.  In  his  own  case  he  had  applied  the 
tincture  of  iodine  with  benefit. 

The  President  said  that  some  years  ago  he  was  consulted  by  a  medical  man 
for  a  similar  affection.    The  application  of  the  strong  tincture  of  iodine  cured  it. 

Dr.  Crisp  said  he  believed  that,  if  pathologists  would  oil  their  hands  before 
they  made  their  examinations,  they  would  not  suffer  from  such  affections. — Med. 
Times  and  Gaz.,  Oct.  25,  1862. 

32.  Eczema  of  the  External  Auditory  Meatus. — We  find  in  the  Glasgow 
Medical  Journal  (April,  1862)  some  practical  remarks,  by  Dr.  T.  M'Call  Ander- 
son, on  this  not  uncommon,  and  so  far  as  our  experience  goes,  troublesome  and 
very  refractory  affection.  "It  may  occur,"  he  states,  "in  connection  with  ecze- 
matous  eruptions  on  other  parts  of  the  body,  but  the  local  causes  specially 
operating  are  the  introduction  of  pins,  ear-picks,  and  acrid  substances  into  the 
meatus.  The  patient  sometimes  complains  of  a  feeling  of  fulness  in  the  ear, 
but  the  itching  is  the  most  annoying  symptom,  to  allay  which,  pin^  ear-picks, 
&c,  are  frequently  introduced,  so  as  to  scratch  the  parts — the  finger  nails,  which 
are  employed  for  a  like  purpose  on  other  parts  of  the  body,  being  inadmissible. 
In  this  way  the  irritation  is  relieved  for  the  moment,  and  the  disease  proportion- 
ately aggravated.  The  calibre  of  the  meatus  is  narrowed,  often  so  much  so  that 
the  membrane  of  the  tympanum  cannot  be  distinctly  seen,  the  amount  of  the 
narrowing  being  dependent  upon  the  amount  of  infiltration  of  its  walls.  There 
is  always  exudation  from  the  meatus  at  some  stage  of  the  disease,  and  the  fluid 
which  exudes  is  either  milky  or  watery,  and  sometimes  so  extensive  as  almost 
to  soak  the  pillow  at  night.  If  the  ear  is  not  frequently  washed  out,  the  exuda- 
tion has  a  very  bad  odour.  At  other  stages  the  meatus  may  be  quite  dry  and 
scaly,  and  in  connection  with  this  condition,  I  have  frequently  noticed  the  sur- 
face of  the  membrane  of  the  tympanum  to  be  dry  and  scaly  also.  Sometimes 
large  quantities  of  epithelium  are  thrown  off  from  the  meatus,  so  as  to  block  it 
up,  and  cerumen  is  sometimes  mixed  up  with  the  epithelial  mass.  The  secretion 
from  the  ceruminous  glands  is,  however,  for  the  most  part  arrested  in  this  affec- 
tion. The  hearing  power  is  often  not  much  impaired;  the  amount  of  deafness 
depending  upon  the  amount  of  infiltration  of  the  walls  of  the  canal,  upon  the 
quantity  of  epithelium  and  discharge  accumulated  in  the  meatus,  and  upon 
whether  the  drum  and  mucous  membrane  of  the  cavity  of  the  tympanum  are  im- 
plicated or  not.  Sometimes  the  deafness  is  so  great  that  the  tick  is  only  heard 
when  the  watch  is  close  to  the  ear.  The  cure  is  often  tedious,  as  it  is  impos- 
sible to  apply  local  remedies  so  well  to  the  meatus  as  to  the  skin ;  and  strong 


1863.]  Medical  Pathology  and  Therapeutics.  215 


local  applications  must  be  used  with  caution  on  account  of  the  delicate  struc- 
tures at  the  bottom  of  the  meatus.  Internal  medicines  appear  to  exercise  very- 
little  influence  over  the  eruption.  Arsenic,  for  instance,  which  sometimes 
removes  eczema  with  almost  incredible  rapidity,  is,  as  far  as  my  experience 
goes,  quite  useless ;  and,  indeed,  I  have  noticed  that  a  limited  eruption  is,  as  a 
general  rule,  much  less  under  the  influence  of  internal  remedies  than  one  which 
attacks  a  large  portion  of  the  cutaneous  envelop.  Purgatives  are  useful  as 
regards  a  temporary  alleviation  of  this  complaint,  but  I  doubt  much  if  they 
produce  any  very  permanent  beneficial  effect.  We  must  trust,  then,  mainly  to 
local  measures,  the  first  of  which  consists  in  washing  out  the  meatus  once  or 
twice  daily  with  tepid  water,  with  a  good  syringe,  such  as  that  manufactured  by 
Messrs.  Savory  and  Moore,  instead  of  those  trumpery  little  glass  things  which 
apothecaries  usually  keep,  and  which  are  too  frequently  made  in  the  most  care- 
less manner.  If  the  meatus  is  not  exuding,  but,  on  'the  contrary,  is  dry  and 
scaly,  it  may  be  necessary  to  drop  a  little  almond  oil  into  it,  so  as  to  soften  the 
particles  and  facilitate  their  subsequent  removal  with  the  syringe.  After  all 
the  effete  matter  has  thus  been  removed,  I  am  in  the  habit  of  painting  the  walls 
of  the  meatus  with  solutions  of  potassa  fusa  (commencing  usually  with  gr.  x  to 
the  ounce  of  water,  but  the  strength  must  be  proportioned  to  the  severity  of  the 
disease).  A  small  paint  brush  is  dipped  in  the  solution,  and  gently  stripped,  so 
.that  it  does  not  contain  too  much  fluid,  and  then  insinuated  into  the  meatus  for 
the  extent  of  half  an  inch,  and  twisted  round,  so  that  the  walls  of  the  canal  are 
entirely  moistened  by  the  fluid.  This  usually  causes  considerable  pain,  which, 
however,  subsides  in  a  few  minutes.  If  the  action  is  very  severe,  it  may  be 
checked  at  once  by  the  injection  of  tepid  water ;  for  which  purpose  I  am  in  the 
habit,  previous  to  the  operation,  of  filling  a  syringe  with  it,  and  holding  it  in 
readiness  for  use  if  required.  If  a  strong  solution  is  used  (e.  g.  gi  to  we  must 
be  careful  not  to  take  up  so  much  fluid  with  the  brush  that  it  drops  upon  the 
drum,  as  the  applications  which  are  appropriate  to  the  walls  of  the  canal  cannot 
always  be  applied  with  impunity  to  the  delicate  structures  at  the  bottom  of  the 
meatus.  In  cases  where  the  drum  participates  in  the  disease,  as  usually  happens, 
a  weak  solution  (e.  g.  potassa  fusa,  gr.  iij  to  %i  of  water)  may  be  used  as  an  in- 
jection night  and  morning,  which  is  sufficiently  strong  to  improve  its  diseased 
condition  in  most  cases.  A  strong  solution  (^i  to  Ji  of  water)  may  usually  be 
painted  on  the  walls  of  the  meatus  every  two  or  three  days,  but  the  more  severe 
the  affection,  and  the  weaker  the  application,  the  oftener  must  it  be  repeated. 
In  the  intervals  between  the  applications — which  I  never  intrust  to  the  patient 
if  the  solution  is  strong — I  direct  him  to  syringe  out  the  ear  twice  daily  with 
tepid  water,  as  before  mentioned.  The  beneficial  effects  of  this  treatment  are 
sometimes  very  marked ;  the  hearing  often  improves  after  a  single  application, 
the  uneasiness  in  the  ear  subsides,  the  meatus  becomes  wider,  and  a  large  quan- 
tity of  serous  fluid  exudes,  which  accounts  for  the  improvement.  If  the  treat- 
ment is  to  be  successful,  each  successive  application  will  be  found  to  improve 
matters  ;  the  amount  of  serum  exuded  will  gradually  diminish,  and  the  meatus 
assume  its  healthy  appearance.  After  the  disease  appears  to  be  gone,  a  weak 
solution  of  potassa  fusa  (gr.  iij  to  %i  of  water)  may  be  painted  on  the  canal 
every  day  or  two  for  a  short  time.  Some  recommend  the  use  of  a  solution  of 
nitrate  of  silver  (^i  to  which  is  used  in  the  same  way  as  the  potassa  fusa 
solution,  but  it  is  not  nearly  so  effectual.  Leeches  are  of  no  use  unless  acute 
pain  occurs  in  the  ear,  indicating  an  acute  attack  of  inflammation,  and  blisters 
behind  the  ears,  recommended  by  Toynbee  and  others,  are,  in  my  experience, 
perfectly  useless." 

33.  An  unusual  Abnormal  Condition  of  the  Mucous  Membrane  of  the  Tongue 
and  Mouth. — Dr.  Neligan  describes  in  the  No.  of  the  Dublin  Quarterly  Journ. 
of  Med.  Sci.  for  August  last  a  very  remarkable  and  highly  interesting  case.  The 
subject  of  it  was  a  gentleman  who  presented  himself  for  examination  for  life 
insurance,  and  the  only  feature  worthy  of  notice  (all  else  being  perfectly  healthy) 
was,  that  "the  tongue  was  singularly  affected,  the  natural  membrane  covering 
it  and  the  inside  of  the  cheeks  being  changed  into  a  thick  white  skin  like  a  kid 
glove,  and  uneven  on  the  surface."    Although  the  author  had  seen  nothing  like 


216 


Progress  op  the  Medical  Sciences.  [Jan. 


it  before,  and  could  give  no  opinion  regarding  it,  he  thought  it  well  to  advise  an 
extra  rate  of  five  or  seven  years  to  be  charged,  "  the  chief  reason  being,  that  if 
any  accident  occurred  to  the  tongue  in  its  abnormal  state  cancer  might  result." 
About  four  years  and  a  half  after  this  the  patient  accidentally  bit  his  tongue ; 
it  became  very  sore,  and  he  was  in  consequence  unable  to  attend  for  examina- 
tion for  a  further  assurance  which  he  was  desirous  of  effecting,  and  the  further 
history  of  the  case  is  thus  given :  "  It  seems  that,  as  the  result  of  this  bite,  a 
small  tubercle  about  the  size  of  a  pea  formed  on  the  edge  of  the  tongue,  beneath 
the  mucous  membrane,  its  situation  being  on  a  level  with  the  molar  teeth.  For 
this  he  sought  the  advice  of  some  of  our  eminent  surgeons,  who  differed  in 
opinion  as  to  the  necessity  of  an  operation,  the  result  being  that  he  placed 
himself  under  the  care  of  one  of  them  who  treated  the  disease  with  caustic 
applications.  After  some  time,  however,  hemorrhage  set  in,  necessitating  an 
operation  which  he  survived  only  a  few  months,  cancer  having  invaded  the 
glands  of  the  neck." 


SURGICAL  PATHOLOGY  AND  THERAPEUTICS,  AND  OPERATIVE  . 

SURGERY. 

34.  Rapid  Spontaneous  Cure  of  Popliteal  Aneurism. — Campbell  de  Morgan, 
Esq.,  Surgeon  to  the  Middlesex  Hospital,  relates  [Med.  Times  and  Gaz.,  Nov. 
22,  1862)  the  following  very  remarkable  and  perhaps  unique  case  of  this,  and 
one  which  opens  a  wide  field  for  speculation  as  to  the  cause  of  the  sudden  arrest 
of  the  pulsation  in  the  aneurism. 

"  George  H.  was  admitted  into  the  Middlesex  Hospital,  under  my  care,  on 
January  4,  1862.  He  was  a  tolerably  healthy-looking  man,  rather  below  the 
average  height;  his  muscular  system  was  well  developed.  He  had  been  once  a 
chimne}r-sweeper;  he  then  became  a  stoker;  and  was  now  a  shoemaker.  His 
habits  were  somewhat  intemperate. 

"  He  was  sent  to  the  hospital  by  Mr.  Shepherd,  a  former  pupil  of  the  hospital, 
to  whom  he  had  applied  in  consequence  of  a  painful  swelling  in  the  right  ham, 
and  who,  on  recognizing  the  nature  of  the  case,  at  once  sent  him  to  the  hospital. 

"  The  swelling  was  at  this  time  small,  and  situated  entirely  between  the  ten- 
dons, which  were  not  displaced  by  it.  It  was  about  two  and  a  quarter  inches 
in  diameter.  The  knee  was  an  inch  more  in  circumference  than  the  opposite 
one.  The  tumour  pulsated  strongly,  and  gave  rise  to  a  considerable  amount  of 
pain.  There  was  no  evidence  of  any  cardiac  or  renal  disease,  or  of  diseased 
arteries  elsewhere.  The  pulse  was  72,  regular  and  firm.  The  aneurismal  thrill 
and  bruit  in  the  tumour  were  very  well  marked. 

"  The  account  he  gave  of  the  occurrence  of  the  tumour  was,  that  on  the  day 
before  Christmas-day,  after  putting  himself  out  of  breath  by  running,  he  was 
shutting  up  the  shop  windows,  when  he  felt  something  give  way  in  the  ham,  and 
a  small  lump  appeared.  For  a  day  or  two  he  paid  no  attention  to  it,  but  three 
days  after  he  felt  an  aching  pain,  and  noticed  that  the  lump  beat  strongly.  Five 
days  after  its  first  appearance,  i.  e.,  December  29,  he  was  unable  to  walk,  and 
the  leg  was  stiff.  Two  days  later,  the  pain  and  throbbing  had  so  much  increasd 
that  he  was  obliged  to  give  up  work. 

"  On  his  admission,  an  attempt  was  made  to  treat  the  case  by  Mr.  Ernest 
Hart's  plan  of  bending  the  leg  on  the  thigh.  The  flexion  stopped  the  pulsa- 
tion ;  but  in  a  short  time  the  posture  became  so  irksome  to  him  that  he  removed 
the  bandages,  and  would  not  again  submit  to  the  treatment. 

"Four  days  after,  the  treatment  by  pressure  was  begun,  the  pad  of  the  tour- 
niquet being  placed  about  the  situation  of  the  junction  of  the  upper  and  middle 
third  of  the  thigh.  A  moderate  amount  of  pressure  checked  the  pulsation  in 
the  aneurism.  The  instrument  was  to  be  worn  during  the  day,  with  occasional 
intermissions,  as  at  meal-time,  and  it  was  taken  off  at  night.  The  tumour  had  at 
this  time  increased  a  little,  and  measured  over  two  inches  and  a  half  in  diameter. 


1863.] 


Surgery. 


217 


"At  first  lie  bore  the  pressure  pretty  well,  but  he  was  evidently  not  very  in- 
telligent, and  was,  moreover,  somewhat  self-willed,  so  that  he  did  nothing  towards 
aiding  the  efforts  of  the  surgeon.  In  three  or  four  days  after  the  application  of 
the  pressure,  he  became  restless  and  feverish.  The  pulsation  was  not  so  marked 
as  at  first,  but  this  was  in  some  degree  owing  to  the  general  swelling  of  the  limb 
from  the  pressure.  Still  the  pressure  was  maintained,  and  the  pulsation  was 
generally  kept  in  check.  On  the  eleventh  day,  however,  the  pain  in  the  tumour 
increased,  and  the  tumour  itself  was  evidently  larger.  The  pain  was  so  severe 
as  to  prevent  his  sleeping.  Although  he  suffered  as  much  when  the  instrument 
was  off  as  when  it  was  on,  he  thought  the  pain  was  brought  on  by  it,  and  was 
very  averse  to  continuing  its  use.  By  the  aid  of  morphia  internally,  and  of  lead 
and  opium  lotion  to  the  knee,  the  pain  was  for  a  time  relieved.  On  the  thirteenth 
day,  the  pain  having  been  very  severe  during  the  previous  night,  he  was  suffer^ 
ing  so  acutely  in  the  tumour,  and  he  had  become  so  excessively  irritable,  that 
no  persuasion  would  induce  him  to  have  the  instrument  reapplied  on  the  thigh. 
I  got  him,  however,  to  try  the  Bead's  compressor,  which  encircles  the  pelvis, 
and  acts  on  the  artery  at  the  groin.  A  moderate  amount  of  pressure  served  to 
stop  the  pulsation.  At  this  time  the  beat  was  far  more  violent  than  at  the  time 
of  his  admission,  and  the  tumour  was  still  increasing  in  size.  It  was,  neverthe- 
less, somewhat  more  solid.  The  skin  was  red,  tense,  and  shining.  The  arteries 
around  the  knee  could  be  felt  pulsating  distinctly.  Although  no  pressure  had 
been  used  since  the  previous  afternoon,  the  pain  in  the  tumour  and  about  the 
knee  was  extremely  severe.  There  was  also  considerable  tenderness ;  the  exami- 
nation of  the  part  gave  rise  to  pain ;  but  still  it  seemed  as  if  it  was  rather  the 
skin  than  the  deeper  parts  which  was  the  seat  of  this,  for  deeper  pressure  did 
not  appear  to  increase  it.  The  pain  appeared  to  be  more  due  to  the  great  ten- 
sion of  the  tumour  than  to  any  inflammation  within  it. 

"  I  had,  at  this  time,  little  hope  of  being  able  to  continue  the  pressure  treat- 
ment under  any  modification,  and  directed  the  house  surgeon  to  call  my  col- 
leagues to  a  consultation  on  the  following  day,  believing  that  it  might  be  neces- 
sary to  tie  the  artery.  The  Read's  compressor  was  meanwhile  applied,  in  the 
hope  that  the  patient  might  be  able  to  tolerate  the  pressure  in  a  new  situation 
for  a  time,  and  that  the  violence  of  the  pulsation  might  be  checked  until  it  was 
determined  what  course  should  be  pursued.  It  was  put  on  at  2.30  P.  M.  He 
only  allowed  it  to  remain  for  about  a  quarter  of  an  hour ;  then  he  took  it  off, 
and  declared  that  he  would  undergo  any  operation,  but  that  he  would  not  bear 
the  pressure  any  longer.  Still  it  was  not  the  pressure  which  was  causing  his  suf- 
ferings ;  they  continued  after  the  instrument  was  removed ;  and  the  house  sur- 
geon, Mr.  Marshall,  found  him,  shortly  after  he  had  removed  it,  in  such  violent 
pain,  that  he  gave  him  a  full  dose  of  opium.  This  produced  no  immediate  effect, 
and  a  quarter  of  an  hour  afterwards  Mr.  Marshall  administered  a  hypodermic 
injection  of  morphia.  At  this  time,  about  a  quarter  past  three,  the  tumour  was 
beating  as  violently  as  ever.  About  twenty  minutes  afterwards,  on  the  house 
surgeon  going  into  the  ward,  the  patient  called  his  attention  to  the  fact  that  the 
pulsation  had  ceased,  and  told  him  that  this  had  taken  place  very  shortly  after 
he  had  left  the  ward,  and,  as  he  (the  patient)  believed,  suddenly.  On  examina- 
tion, it  was  found  that  no  beating  whatever  could  be  detected.  The  man's 
sufferings  were  ended.  The  pain  was  trivial,  compared  with  what  he  had  been 
enduring.  The  tumour  felt  firm  and  doughy ;  the  general  tension  of  the  limb 
was  less,  but  it  presented  nothing  remarkable  in  temperature  or  colour. 

"  From  this  time  there  was  no  trace  of  pulsation,  nor  could  any  sound  be 
heard  through  the  stethoscope.  On  the  following  day,  the  tumour  was  con- 
siderably smaller,  quite  firm,  and  free  from  pain  and  tenderness ;  the  engorge- 
ment of  the  limb  was  subsiding  rapidly.  For  many  days,  the  leg,  below  the 
knee,  was  a  few  degrees  warmer  than  the  opposite  leg,  as  is  frequently  observed 
after  ligature  of  the  vessel.  None  of  the  arteries  of  the  leg  or  foot  could  be 
felt  to  beat,  while  the  vessels  around  the  knee  were  large,  and  pulsated  vigor- 
ously. The  femoral  artery  could  be  traced  by  its  pulsations  from  the  groin  to 
within  an  inch  of  the  tumour.  A  cure  was  effected,  in  short,  much  in  the  same 
way,  so  far  as  the  appearance  of  the  sac  and  its  contents  was  concerned,  as  if  a 
ligature  had  been  placed  on  the  femoral  artery." 


218 


Progress  of  the  Medical  Sciences. 


[Jan. 


35.  Garibaldi's  Wound. — The  discussion  which  has  lately  excited  the  public 
as  well  as  the  profession,  as  to  whether  or  not  the  ball  with  which  the  illustrious 
Italian  patriot  was  injured,  remained  in  the  wound,  has  been  definitely  solved. 
Professor  Zanetti  actually  removed  the  projectile  on  the  23d  of  November  last, 
thus  confirming1  the  diagnosis  of  Nelaton. 

Kespecting  this  favourable  result  M.  Nelaton  made  the  following  remarks  to 
his  class  at  the  Hopital  des  Cliniques : — 

"  When  we  consider  the  variety  of  opinions  which  have  been  offered  respect- 
ing the  presence  of  a  foreign  body  in  the  wound,  it  is  evident  that  the  favourable 
result  lately  obtained  would  have  been  very  long  delayed  had  we  not  means  of 
accurate  diagnosis.  Let  me  remind  you  that  the  wound  is  on  a  level  with  the 
anterior  edge  of  the  inner  malleolus,  which  latter  has  been  fractured  by  the  ball; 
the  wound  runs  in  a  transverse  direction,  and  the  probe,  introduced  about  one 
inch  into  it,  came  in  contact  with  a  hard  body.  The  sound  heard  on  striking  was 
dull,  and  very  unlike  that  produced  by  meeting  with  necrosed  or  carious  bone. 
The  ball  was  lodged  in  front  of  the  neck  of  the  astragalus,  though  its  presence 
could  not  be  detected  by  examination  of  the  instep  in  consequence  of  the  tension 
of  parts  in  that  region.  I  was,  however,  perfectly  certain  that  the  ball  was 
there,  and  advised  gradual  dilatation.  But  M.  Porta,  who  explored  with  his 
finger,  did  not  agree  with  me. 

"On  my  return  to  Paris,  I  endeavoured  to  contrive  exploring  instruments 
which  should  convince  those  who  were  not  of  the  same  opinion  as  myself.  I 
thought,  first,  of  a  sound  ending  in  a  kind  of  file  which  could  take  off  a  few 
metallic  particles.  I  had  some  constructed;  but  M.  E.  Eousseau  gave  me  the 
idea  of  an  instrument  which  would  bring  away  particles  of  metal.  We  had, 
therefore,  a  probe  made,  to  the  end  of  which  was  fixed  an  olive-shaped  body, 
made  of  unpolished  china,  upon  which  mere  contact  would  leave  a  mark  of  the 
projectile,  and  prove  its  presence.  M.  Charriere  made  several  instruments  of 
this  kind,  composed  of  a  silver  stem,  ending  in  a  china  knob.  The  mere  rubbing 
of  this  instrument  against  lead  is  sufficient  to  make  a  stain,  which  neither  the 
soft  parts  nor  the  morbid  secretions  could  obliterate ;  simple  rotation  of  the 
instrument  upon  its  axis  fixes  upon  it  a  kind  of  meridian. 

"But  affirmations  of  mine  are  not  sufficient — proof  is  the  main  thing;  nor  has 
this  been  wanting,  for,  with  ^his  instrument,  Professor  Zanetti  became  so  cer- 
tain of  the  presence  of  the  ball  that  he  forthwith  extracted  it. 

"  Other  instruments  have  been  proposed  to  diagnose  a  ball  at  the  bottom  of 
a  wound.  M.  Favre,  Professor  at  Marseilles,  has  invented  the  following:  Two 
conducting  wires  are  placed  in  a  sheath,  or  the  two  electrodes  may  be  covered 
by  an  isolating  substance.  '  These  wires  are  in  communication  with  a  battery  of 
only  one  couple,  and  a  galvanometer  is  fastened  on  one  of  the  wires.  If  you 
introduce  the  end  of  these  into  a  wound,  the  contact  of  the  soft  parts,  the  bones, 
or  pus,  is  not  sufficient  to  establish  a  current ;  but  if  the  ends  come  in  contact 
with  a  metallic  body,  the  needle  of  the  galvanometer  will  rise,  this  being  a  proof 
that  the  circuit  is  complete.  Only  one  couple,  however,  should  be  used,  so  as 
to  avoid  the  decomposition  of  the  fluids  in  the  wound,  which  decomposition 
would  immediately  give  rise  to  a  current." 

36.  Old  Gunshot  Injury  of  the  Tibia  ;  Recent  Fracture  of  the  Femur. — Mr. 
Tufnell  exhibited  to  the  Pathological  Society  of  Dublin  (Jan.  25,  1862)  the 
tibia  of  an  old  man,  aged  78,  who,  52  years  before,  at  the  battle  of  Busaco,  had 
been  wounded  by  a  musket-ball.  The  bullet  had  lodged  in  the  cancellated 
structure  of  the  head  of  the  bone,  and  been  removed  from  thence  by  means  of  a 
trephine.  The  cavity  formed  by  the  ball  had  never  filled  up,  but  remained  an 
open,  discharging  wound,  lined  by  a  pyogenic  membrane,  and  daily  secreting  a 
quantity  of  fetid  pus.  The  integuments  were  adherent  around  the  edge  of  this 
opening.  No  treatment  had  been  adopted  beyond  keeping  the  part  clean,  and 
placing  over  the  opening  into  the  bone  a  piece  of  linen  smeared  with  grease. 

The  presence  of  this  cavity  in  the  head  of  the  bone  had  not  caused  much 
annoyance,  and  for  five-and-forty  years  he  had  laboured  regularly  as  a  brick- 
layer's assistant. 

About  six  years  since,  finding  himself  to  be  getting  infirm,  he  became  an  in- 


1863.] 


Surgery. 


219 


pensioner  of  Kilmainham  Hospital,  where  he  remained  until  the  period  of  his 
death,  which  arose  in  the  following  manner :  Like  most  old  soldiers  he  was 
given  to  drinking,  and  took  his  liquor  freely,  but  not  to  prejudicial  effects,  until 
two  days  before  his  decease,  when  he  got  very  drunk,  and  fell  helplessly  whilst 
crossing  his  room,  fracturing  the  left  femur  through  the  trochanters  by  the  direct 
violence  of  the  blow. 

When  brought  to  the  infirmary  the  limb  was  shortened,  but  not  to  any  great 
degree.  The  foot  everted ;  and  before  the  groin  a  considerable  projection  formed. 
He  complained  of  no  pain,  but  was  incoherent,  and  this,  in  all  probability,  re- 
sulting from  intoxication  more  than  shock.  He  had  been  suffering  for  some 
days  from  diarrhoea.  Stimulants  and  support  were  given,  but  he  never  rallied, 
and  died  in  40  hours  from  the  receipt  of  the  injury. 

Upon  examination  of  the  parts  in  the  vicinity  of  the  fracture,  they,  and  indeed 
the  whole  thigh,  on  its  front  and  outer  aspect,  were  found  gorged  with  black 
blood,  every  tissue  being  infiltrated  with  it.  The  fracture  of  the  femur  extended 
obliquely  through  both  trochanters,  the  upper  portion  of  the  lower  fragments 
being  in  front  of  and  lying  upon  the  upper  fragment. 

With  reference  to  the  cavity  in  the  head  of  the  tibia,  it  differed  greatly  from 
that  observed  in  a  somewhat  similar  case  by  the  late  Sir  George  Ballingall,  of 
Edinburgh,  and  reported  in  his  Military  Surgery  Museum,  in  this  respect,  viz., 
that  the  enlargement  of  the  head  of  the  bone  was,  in  his  case,  excessive,  whilst 
here  its  size  was  in  no  way  affected. 

In  Sir  George  Ballingall's  case  the  individual  had  lived  to  a  very  advanced 
period  of  life,  labouring,  too,  for  his  bread,  but  working  as  a  boatman ;  and, 
finding  inconvenience  from  the  oozing  of  pus,  he  had  plugged  the  orifice  with 
a  wine  bottle  cork.  Nature,  to  resent  this  irritation,  had  thrown  out  new  bone, 
whilst  absorption,  by  the  pressure  of  the  foreign  body,  had,  at  the  same  time, 
been  going  on  from  within,  necessitating  the  enlargement  of  the  plug,  until,  at 
the  period  of  his  death,  it  required  a  piece  of  deal  as  large  as  a  bung,  wrapped 
round  with  old  linen,  to  stop  the  vent. 

Each  day  the  old  veteran  used  to  take  out  the  stopper,  and  holding  his  leg 
over  the  side  of  the  boat,  wash  out  the  cavity  well  with  sea  water,  and  then  close 
it  for  24  hours,  when  the  process  was  repeated. 

Mr.  Tufnell  was  indebted  to  his  friend,  Dr.  William  Carte,  physician  and  sur- 
geon to  Kilmainham  Hospital  for  the  opportunity  of  exhibiting  this  case. — ■ 
Dublin  Quart.  Journ.  Med.  Sc.,  Nov.  1862. 

37.  Blow  on  the  Head — Sudden  Death  two  years  after  from  the  Injury.— 
M.  de  Closmadetjc  communicated  to  the  Socie'U  de  Chirurgie  a  case  illustrating 
the  propriety  of  giving  a  cautious  prognosis  in  cases  of  violent  blows  on  the 
head. 

A  soldier,  in  leaping  over  a  rampart,  fell  on  his  head.  After  some  moments 
loss  of  consciousness,  he  recovered  and  returned  to  his  quarters.  He  resumed 
his  duties,  and  his  health  appeared  uninjured.  Nevertheless,  he  was  affected  at 
times  with  headache,  which  lasted  for  some  hours,  and  sometimes  for  two  days. 
Two  years  after  his  fall  he  died  suddenly  on  the  field  during  drill.  For  some 
time  previously  he  had  lost  flesh,  and  his  countenance  was  altered,  but  his  intel- 
lectual functions  and  locomotive  powers  were  unimpaired. 

On  post-mortem,  an  abscess  was  discovered  in  the  white  substance  of  the 
brain  ;  this  abscess  was  evidently  not  of  recent  formation.  By  the  side  of  this 
abscess  was  a  recent  ventricular  hemorrhage,  produced  by  the  sudden  rupture 
of  the  septum  which  separated  the  abscess  from  the  ventricle  ;  and  this  hemor- 
rhage had  produced  sudden  death. —  Gazette  Hebdom.,  5  Sept.  1862. 

38.  Reunion  of  Intracapsular  Fractures  of  the  Femur. — M.  Fabri,  of 
Bologna,  has  published  some  interesting  cases  in  which  reunion  followed  this 
ordinarily  intractable  fracture.  The  first  was  that  of  a  man  whose  body  was 
brought  to  the  dissecting-room,  and  who  had  long  used  crutches.  An  intra- 
capsular fracture  was  discovered  which  had  been  perfectly  reunited  by  the 
formation  of  an  osseous  substance.  Previous  to  the  occurrence  of  osseous 
union,  however,  so  much  displacement  and  separation  of  the  fragments  had  taken 


220 


Progress  of  the  Medical  Sciences. 


[Jan. 


place  that  lameness  resulted.  The  spongy  substance  of  the  head  was  united 
with  that  of  the  neck  by  the  medium  of  a  compact  layer  of  new  bone,  four  milli- 
metres thick.  In  the  second  case  (a  man  set.  70),  the  circumstances  were 
similar,  only  the  union  was  by  means  of  singularly  dense  cartilage,  instead  of 
bone.  In  neither  of  these  cases  was  there  any  penetration  of  the  neck  of  the 
femur  into  the  spongy  tissue  of  the  great  trochanter.  In  a  third  case  (a  man 
set.  77)  the  patient  was  able  to  walk  in  less  than  a  year  after  the  accident,  which 
he  survived  for  seven  years.  Complete  osseous  reunion  was  found,  on  post- 
mortem examination,  to  have  taken  place. — London  Med.  Rev.,  Aug.  1862,  from 
Presse  Mtdicale  Beige. 

39.  Portion  of  Food  Impacted  in  the  Larynx. — Mr.  Spence  showed  to  the 
Medico-Chirurgical  Society  of  Edinburgh  (2d  July,  1862)  a  very  remarkable  pre- 
paration, for  which  he  was  indebted  to  a  former  pupil.  A  little  boy,  between  eleven 
and  twelve  years  of  age,  had  been  for  some  time  subject  to  paroxysms  of  difficult 
breathing,  and  in  the  intervals  had  huskiness  of  the  voice.  While  at  dinner  one 
day,  he  was  suddenly  attacked  with  urgent  dyspnoea,  which  his  parents,  however, 
believed  to  be  merely  one  of  his  ordinary  paroxysms.  A  medical  man  was  im- 
mediately sent  for,  and  arrived  very  soon ;  in  the  meantime,  the  parents  had  a 
warm  bath  prepared,  which  was  the  treatment  usually  adopted  for  the  spasmo- 
dic attacks.  On  his  arrival,  the  doctor  had  him  put  in  the  bath,  and  passed  his 
finger  into  the  pharynx ;  cold  water  was  poured  over  the  boy,  and  consciousness 
was  restored.  On  being  asked  if  he  felt  any  pain,  he  placed  his  hand  over  the 
windpipe,  and  said  "here  ;"  and  immediately  expired.  On  post-mortem  exami- 
nation, the  whole  of  the  lower  part  of  the  larynx  and  upper  part  of  the  trachea 
was  occupied  by  a  piece  of  meat,  so  firmly  impacted,  that,  as  could  be  seen,  a 
bristle  could  hardly  be  passed  along.  Under  these  circumstances,  it  was  very 
remarkable  that  the  boy  could  have  breathed  for  a  single  instant.  In  writing 
to  make  some  inquiries  regarding  the  history  of  the  case,  Mr.  Spence  had  been 
particular  to  ask  whether  the  body  might  not  have  been  pushed  down  to  its  pre- 
sent situation.  The  answer  was  decidedly  in  the  negative,  the  medical  man 
having  merely  swept  his  finger  round  the  back  part  of  the  mouth.  A  number 
of  enlarged  glands  had  been  found  pressing  upon  the  trachea,  which  had  pro- 
bably been  the  cause  of  the  previous  attacks  of  difficult  breathing. — Ed.  Med. 
Journ.,  Sept.  1862. 

40.  Tracheotomy  Tube  dropped  into  Left  Bronchus. — Mr.  Spence  mentioned 
to  the  Medico-Chirurgical  Society  of  Edinburgh  (June  4,  1862)  the  particulars 
of  a  rare  accident  which  had  come  under  his  notice.  A  man  had  had  trache- 
otomy performed  several  years  ago  by  Mr.  Edwards,  and  had  since  worn  a  dou- 
ble tube.  Yesterday,  while  riding  on  horseback,  the  rim  of  the  tube,  which  had 
been  gradually  wearing,  gave  way,  and  it  fell,  as  the  man  expressed  it,  "into  his 
chest."  The  man  went  at  once  to  Mr.  Edwards'  house,  but  as  that  gentleman 
was  from  home,  his  assistant  put  in  another  tube  and  sent  him  to  the  hospital, 
where  he  came  under  Mr.  Spence's  care.  When  Mr.  Spence  saw  the  patient 
he  was  breathing  quite  freely,  and  the  sounds  on  auscultation  were  very  much 
the  same  on  the  two  sides  of  the  chest.  A  probe  was  in  the  first  instance  passed 
down  into  the  right  bronchus  (into  which  it  was  generally  said  that  foreign 
bodies  fell),  but  nothing  was  felt;  it  was  then  passed  into  the  left  bronchus  and 
the  tube  was  at  once  felt.  An  attempt  was  then  made  to  extract  the  tube  with- 
out enlarging  the  wound,  but  was  unsuccessful.  Chloroform  was  then  adminis- 
tered, the  opening  was  enlarged  by  cutting  through  two  or  three  of  the  rings  of 
the  trachea,  a  pair  of  bent  forceps  was  introduced,  the  tube  was  seized,  drawn 
to  the  opening,  and  then  extracted.  Mr.  Spence  observed  that  so  far  as  he 
knew  this  was  the  only  case  of  the  kind,  but  it  should  teach  cutlers  to  make 
their  tubes  in  two  lateral  halves  and  then  join  them  together;  for  when,  as  at 
present,  the  shield  was  fastened  to  the  tube,  the  soldering  must  iu  course  of  time 
give  way. — Ed.  Med.  Journ.,  Aug.  1862. 

41.  Use  of  Nicotia  in  Tetanus  and  in  Poisoning  by  Strychnia. — Professor 
S.  Hal'g'hton  laid  before  the  Royal  Irish  Academy,  in  1856,  some  experiments 


1863.] 


Surgery. 


221 


made  by  him  .on  the  physiological  action  of  nicotia  and  strychnia  on  frogs,  which 
appear  to  show  that  the  action  of  these  two  alkaloids  are  antagonistic  to  each 
other,  at  least  in  frogs.  After  reading  a  case  related  by  Dr.  O'Reilly,  in  which 
an  infusion  of  tobacco  leaves  had  been  successfully  administered  in  a  case  of 
poisoning  by  strychnia,  it  occurred  to  Mr.  H.  that  nicotia  might  be  usefully  em- 
ployed in  tetanus  as  well  as  in  strychnia  poisoning.  Through  the  kindness  of 
the  physicians  of  several  of  the  Dublin  hospitals,  Mr.  H.  has  had  the  opportunity 
of  testing  the  correctness  of  his  views,  and  in  a  communication  made  to  the  Col- 
lege of  Physicians  in  Ireland  (March  19, 1862),  he  relates  several  cases  in  which 
the  nicotia  was  used  with  advantage. 

The  first  case  was  one  of  tetanus  following  an  extensive  and  severe  burn,  in 
which  the  nicotia  relieved  the  agonizing  pain,  and  relaxed  the  spasms,  but  the 
patient  died  from  the  attendant  surgical  double  pneumonia. 

The  second  case  was  one  of  idiopathic  subacute  tetanus  from  exposure  to 
cold,  in  which  during  eleven  days  26.4  grains  of  nicotia  was  given.  The  patient 
recovered. 

The  alkaloid  in  this  case  produced :  1.  Immediate  relaxation  of  the  muscles 
of  the  abdomen,  back,  and  diaphragm. 

2.  It  caused  cessation  of  delirium, 

3.  There  was  a  slight  tendency  to  cause  increased  circulation,  to  the  extent 
of  10  beats  per  minute. 

4.  It  caused  profuse  sweating,  which  exhaled  an  intolerable  odour  of  snuff, 
not  of  tobacco. 

5.  It  had  a  tendency  to  produce  deep  sleep. 

6.  It  failed  to  control  quickly  the  adductor  muscles  supplied  by  the  obturator 
nerve;  and  even  when  the  hamstring  muscles  gave  way,  the  adductors  refused. 

The  third  case  was  an  attempted  suicide  with  strychnia,  in  which  an  infusion 
of  tobacco  was  given,  which  produced  vomiting  when  all  other  means  had  failed, 
and  further  counteracted  the  action  of  the  strychnia  already  absorbed. 

Mr.  H.  also  gives  a  brief  notice  of  a  case  of  traumatic  tetanus,  under  the  care 
Mr.  Tufnell,  at  Baggot  Street  Hospital,  successfully  treated  by  nicotia. 

The  nicotia  was  given  in  doses  of  half,  1,  2,  and  2^-  drops,  each  drop  contain- 
ing six-tenths  of  a  grain  of  nicotia. — Dublin  Quarterly  Journ.  Med.  Sci.,  Aug. 
1862. 

42.  On  the  Use  of  Iodine  Injections  in  Large  Acute  Abscesses. — M.  Cosmao- 
Dumenez  having  had  the  opportunity  of  observing,  under  M.  Demarquay,  the 
great  utility  of  iodine  in  the  treatment  of  acute  inflammations  and  of  large  ab- 
scesses, which  ordinarily  are  so  tedious  in  their  course,  is  desirous  of  calling 
attention  to  the  subject.  As  examples,  he  relates  two  cases  of  deep-seated 
abscesses — the  one  in  the  region  of  the  groin,  and  the  other  in  that  of  the  but- 
tock— in  which  a  few  iodine  injections  proved  rapidly  curative,  notwithstanding 
that  the  amount  of  pus  discharged  on  opening  the  abscesses  had  been  very 
large.  Most  of  the  cases  observed  by  the  author  under  M.  Demarquay  were 
abscesses,  accompanied  by  much  detachment  of  skin,  in  the  groin,  axilla,  popli- 
teal space,  &c,  and  examples  of  phlegmonous  erysipelas.  The  tediousness  of 
the  ordinary  modes  of  treatment,  even  aided  by  compression,  and  the  frequency 
with  which  formidable  accidents  arise,  are  but  too  well  known ;  while  the  iodine 
expedites  the  cure,  and  obviates  these"  various  inconveniences.  By  its  aid, 
according  to  M.  Monod,  suppurative  is  converted  into  adhesive  inflammation, 
plastic  lymph  taking  the  place  of  pus.  Moreover,  a  portion  of  the  iodine  injected 
becomes  absorbed  into  the  system,  as  manifested  by  its  appearance  in  the  secre- 
tions, and  may  influence  the  deteriorated  constitution  beneficially.  The  formula 
employed  by  MM.  Monod  and  Demarquay  is :  water,  100 ;  alcohol,  50 ;  iodine,  5  ; 
and  iodide  of  potassium,  5  parts,  all  by  weight.  When  there  is  great  sensitive- 
ness, this  may  be  diluted  by  one-fourth  or  one-half  of  water.  As  the  injection 
should  be  made  to  penetrate  into  all  the  sinuosities  of  the  purulent  cavity,  a 
syringe  strong  enough  to  throw  it  with  force  must  be  employed ;  and  M.  Demar- 
quay annexes  to  the  mouth  of  the  syringe  a  gutta  percha  catheter.  The  cavity 
should  be  first  cleansed  out  by  means  of  tepid  water,  the  iodine  being  injected 
as  soon  as  this  has  been  gently  pressed  out.    The  catheter  is  then  to  be  removed, 


222 


Progress  op  the  Medical  Sciences. 


[Jan. 


and  any  of  the  iodine  allowed  to  run  out  which  may  do  so  unaided  by  pressure. 
If  there  are  several  apertures,  they  should  all  be  injected — unless,  indeed,  the 
iodine  entering  by  one  runs  out  by  the  others.  At  the  end  of  forty-eight  hours, 
unless  the  pus  has  changed  in  nature  and  quantity,  the  injection  must  be  re- 
peated ;  and  M.  Monod  states  that  he  has  several  times  seen  this  mode  of  treat- 
ment cut  short  those  troublesome  suppurations  which  gradually  invade  almost 
an  entire  breast — a  disease  thus  becoming  terminated  in  ten  or  fifteen  days 
which  otherwise  might  have  continued  for  months. — Brit,  and  For.  Med.-Chir. 
Review,  Oct.  1862,  from  Bull,  de  The'rap.,  t.  lxii. 

43.  Treatment  of  Chronic  Swelling  of  the  Bursa  Patellce,  by  Puncture  and 
the  Injection  of  a  Solution  of  Iodine. — Dr.  Robert  Kirkwood  states  [Glasgow 
Medical  Journal,  Jan.  1862)  that  the  ordinary  method  of  treating  chronic  swell- 
ing of  the  bursa  patellse,  being  troublesome,  painful,  and  tedious,  and  the  result 
seldom  satisfactory,  he  was  induced,  in  1859,  to  try  the  effect  of  puncturing  the 
tumour,  evacuating  its  contents,  and  injecting  a  solution  of  iodine.  The  result 
was  satisfactory,  and  he  has  now  treated  three  cases  by  this  plan. 

His  "  first  case  was  that  of  a  young  woman,  a  domestic  servant,  who  more 
than  a  year  before  had  observed  a  small,  painless  swelling,  for  which  she  could 
assign  no  cause,  in  front  of  her  right  knee.  It  increased  slowly  in  size,  and  when 
I  first  saw  it,  was  about  as  large  as  an  orange,  and  soft  and  fluctuant.  She 
complained  only  of  the  weakness  and  inconvenience  which  it  occasioned  her. 
With  a  trocar  and  canula,  such  as  is  used  in  the  operation  for  hydrocele,  I  punc- 
tured the  swelling  at  the  most  dependent  point,  and  after  evacuating  the  straw- 
coloured  serous  contents,  injected  a  solution  of  iodine  and  retained  it  for  a  minute 
or  two.  The  canula  being  now  withdrawn,  a  piece  of  lint  was  placed  over  the 
wound,  and  a  short  staight  splint  applied  along  the  limb  and  retained  with  a 
roller.  The  following  day,  the  patient  complained  of  a  little  pain  in  the  knee,  and 
there  was  also  slight  swelling,  which  was  fluctuant.  I  passed  a  probe  along  the 
course  of  the  puncture,  and  evacuated  a  small  quantity  of  a  brownish-coloured 
serous  fluid.  There  was  no  constitutional  disturbance  ;  the  local  was  so  trifling 
as  scarcely  to  deserve  mention ;  and  by  the  fifth  or  sixth  day,  I  forget  which, 
the  knee,  though  a  little  weak,  was  perfectly  well. 

"The  second  case,  also  occurring  in  a  young  domestic  servant,  bore  consider- 
able resemblance  to  the  first,  with  the  exception  that  from  its  history  it  appeared 
to  be  the  consequence  of  an  attack  of  acute  bursitis  ;  and  besides  the  weakness 
and  inconvenience  to  which  it  gave  rise,  was  at  times  also  more  or  less  painful. 
It  was  treated  in  precisely  the  same  way  and  with  the  same  satisfactory  result. 

"The  third  case  occurred  in  a  young  man,  a  joiner,  and  was  more  recent  than 
the  others.  The  stiff,  firm,  leathery  feel  of  the  tumour  gave  the  idea  of  a  thick- 
ened sac,  and  this,  after  puncture,  was  found  to  be  the  case.  The  contents  were 
sero-sanguineous.  On  two  different  occasions  I  passed  a  probe  along  the  course 
of  the  puncture  to  evacuate  a  small  quantity  of  fluid  ;  but  in  five  days  the  knee 
was  well,  though  by  my  advice  patient  did  not  resume  his  work  till  the  expiry 
of  a  week  from  the  date  of  the  operation. 

"It  is  now  about  three  months  since  I  operated  on  this  case,  and  the  cure  up 
to  this  date  seems  perfect.  Some  thickening  still  remains,  but  under  the  use  of 
iodine  paint  it  has  diminished  considerably.  The  second  case  was  operated 
upon  in  June  of  last  year.  The  patient  has  gone  from  under  my  observation, 
but  her  knee,  her  mother  informs  me,  is  strong  and  well,  and  shows  no  indica- 
tions of  anything  having  ever  been  the  matter  with  it.  I  saw  my  first  case  the 
other  day ;  no  trace  remains,  and  patient  states  that  her  knee  is  as  strong  as  ever. 

"In  each  case,  in  consequence  of  a  slight  feeling  of  weakness  remaining  after 
the  operation,  though  less  than  before  it,  I  recommended  an  elastic  knee-cap  to 
be  worn  for  a  few  weeks,  by  the  end  of  which  time  the  feebleness  had  dis- 
appeared." 

44.  Subcutaneous  Treatment  of  Boils  and  Carbuncles. — Mr.  J.  G.  French, 
Surgeon  to  St.  James's  Infirmary,  Westminster,  states  (London  Med.  Review, 
Sept.  1862)  that  he  has  occasionally,  during  many  years,  adopted  the  following 
mode  of  treatment  of  boils  and  carbuncles  with  great  advantage. 


1863.] 


Surgery. 


223 


"  The  extent  of  the  induration  of  the  integument  is  first  carefully  examined, 
and  then  a  tenotomy  knife  is  passed  horizontally  underneath  it,  the  blade  turned 
upwards,  and,  the  forefinger  of  the  left  hand  serving  as  a  guide  upon  the  upper 
surface  of  the  tumour,  the  hardened  structure  is  cut  through,  taking  care  not  to 
wound  the  surface  of  the  skin ;  it  is,  in  fact,  a  subcutaneous  division  of  the  dis- 
ease, and  is  carried  to  the  utmost  extremity  of  the  induration. 

"  The  disease,  previously  spreading,  is  at  once  arrested  in  the  direction  of  the 
knife,  but  it  is  necessary  to  make  a  second  puncture  at  right  angles  with  the 
first,  and  thus  a  crucial  incision,  or  it  will  still  spread  in  the  opposite  direction. 
The  bleeding  is  sometimes  considerable,  sometimes  trifling,  and  when  this  has 
ceased,  the  whole  surface  of  the  tumour  should  be  covered  with  collodion. 

"  Immediate  relief  is  felt  by  the  patient  as  the  result  of  this  proceeding,  and 
he  is  able  at  once  to  pursue  his  ordinary  avocations. 

"  The  inflammation  speedily  resolves,  or  if  any  suppuration  whatever  occurs, 
it  is  in  very  small  quantity,  and  easily  finds  vent  through  one  of  the  punctures. 

"  This  operation  being  somewhat  slow  and  painful  it  is  only  where  an  imme- 
diate result  is  greatly  desired  that  I  venture  to  adopt  it,  preferring  generally 
the  quicker  method  of  dividing  the  integument  completely,  but  it  is  interesting 
to  know  the  fact  of  its  invariable  efficacy.  An  inquiry  is  often  made  by  the  pa- 
tient whether  the  malady  will  return  elsewhere  if  thus  suddenly  arrested  ?  I  do 
not  find  that  a  second  boil  or  carbuncle  occurs  when  thus  interrupted  more  fre- 
quently than  when  the  disease  is  left  to  take  its  course  ;  on  the  contrary,  where 
poultices  are  used  a  recurrence  is  frequent;  indeed,  this  remedy,  when  used  for 
other  disorders,  often  seems  to  produce  the  disease. 

"  With  regard  to  larger  and  more  neglected  carbuncles,  where  the  life  of  the 
patient  is  endangered  by  their  extent,  it  is  worth  while  making  the  remark  that 
the  disease  can  at  any  time  be  arrested  by  the  knife  while  it  is  still  spreading. 
But  the  crucial  incision  is  often  insufficient  where  the  disease  has  acquired  the 
size  of  a  cheese  plate.  It  will  spread  at  the  circumference  between  the  longi- 
tudinal and  lateral  incisions  at  some  point  or  other,  and  an  incision  made  here 
at  once  still  arrests  its  progress.  A  large  carbuncle  will,  therefore,  often  require 
to  be  starred  to  arrest  it  completely. 

"What  is  called  opening  a  carbuncle,  that  is,  making  a  free  incision  simply 
or  crucially  in  the  centre,  does  not,  so  far  as  my  observation  goes,  appear  to  do' 
much  good ;  and  I  think  the  doubt  about  the  good  effect  of  operative  procedure, 
which  exists  in  the  minds  of  some,  is  due  to  the  observation  of  this  method 
alone." 

45.  How  to  Relieve  Pain  in  Diseased  Bladder. — The  presence  of  urine,  and 
more  especially  of  uric  or  phosphatic  calculi  or  concretions  at  the  bas-fond  of  a 
diseased  bladder,  sometimes  produce  violent  pains  in  the  bladder,  and  render  all 
movement  painful.  In  such  cases,  if  the  patient  be  placed  on  an  inclined  plane, 
which,  by  raising  the  lower  part  of  the  pelvis,  throws  the  contents  of  the  blad- 
der towards  the  upper  and  posterior  part  of  the  cavity  (which  is  much  less  sen- 
sitive), relief  is  almost  immediately  produced,  even  though  other  means  have 
been  tried  in  vain. — Brit.  Med.  Journal,  Feb.  1, 1862,  from  Rev.  de  Th6r.  Med.- 
Chir.,  Dec.  1,  1861. 

46.  Deafness  Consequent  on  Rheumatism — Noise  in  the  Ears. — A  case  of 
deafness  consequent  on  rheumatism,  treated  by  Mademoiselle  Cleret's  method, 
has  been  related  by  Dr.  Delioux.  A  cannonier,  51  years  of  age,  had  an  attack 
of  acute  rheumatism  six  months  previously,  which  passed  into  the  chronic  form, 
and  was  accompanied  by  deafness  of  the  left  ear,  with  diminution  of  hearing  in 
the  right  ear,  frequent  buzzing  at  both  ears,  but  no  discharges.  Keceived  into 
the  Marine  Hospital  at  Toulon,  he  was  subjected  to  the  instillation  of  ether  in 
both  ears.  He  immediately  felt  a  kind  of  expansion  in  the  interior  of  the  ear, 
accompanied  by  a  slight  pain,  but  at  once  his  conception  of  sounds  became  less 
confused.  Next  day  he  declared  that  he  heard  with  his  right  ear  as  well  as 
before  his  illness.  The  instillation  was  now  only  applied  to  the  left  ear,  and 
repeated  three  times  on  the  following  day.  On  the  fourth  day  the  hearing  of 
both  ears  was  perfectly  restored.    The  general  rheumatism  was  treated  with 


224 


Progress  of  the  Medical  Sciences. 


[Jan. 


sulphureous  baths,  and  the  vinum  Ardurani  during  the  following  month,  under 
the  apprehension  that  the  deafness  might  return  as  long  as  any  rheumatism 
continued. 

The  composition  of  vinum  Ardurani  is  as  follows :  Bulb  of  colchicum  30  parts ; 
leaves  of  fraxinus  ornus  38  parts ;  Malaga  wine  300  parts.  Macerate  during 
eight  days  and  strain  off;  then  add  tincture  of  aconite  8  parts;  tincture  of  di- 
gitalis 5  parts.    A  large  teaspoonful  to  be  taken  morning  and  evening. 

Dr.  Delioux  gives  two  other  cases  of  rheumatic  deafness  treated  in  the  same 
way,  but  in  which  there  was  only  an  improvement  and  not  a  complete  cure. 
This  he  explains  by  the  general  disease  predominating  over  the  local  affection. 

Among  other  facts  confirming  this  view  respecting  the  connection  between 
noises  in  the  ear  and  imperfections  of  hearing  with  rheumatism,  and  in  an  espe- 
cial manner  proving  the  use  of  instillations  of  ether  in  this  particular  kind  of 
deafness,  one  related  by  M.  Bellemont  should  not  be  omitted.  A  labourer,  60 
years  of  age,  subject  to  rheumatic  pains  in  his  limbs,  found  after  some  time  that 
they  all  became  concentrated  in  his  head,  and  during  a  year  he  became  so  deaf 
as  to  give  up  the  enjoyment  of  conversation.  He  described  a  sound  in  his  ears 
like  that  of  a  swarm  of  bees.  After  an  ineffectual  trial  of  several  remedies,  M. 
Berlemont  applied  two  instillations  of  ten  drops  of  ether  at  the  interval  of  a 
quarter  of  an  hour.  Immediately  he  began  to  hear  distinctly.  The  same  treat- 
ment has  been  continued,  and  deafness  and  noise  in  the  ears  are  now  completely 
removed. 

A  series  of  similar  facts  has  been  received  from  M.  Coursier,  the  most  remark- 
able of  which  occurred  in  children  complaining  of  noises  in  the  ears.  In  one 
of  these  the  patient,  seven  years  of  age,  could  not  bear  the  application  of  the 
ether.  By  mixing  it  with  one-half  of  glycerine  the  object  was  accomplished. 
M.  Debout,  however,  states  that  although  glycerine  succeeds  in  eczematous 
deafness,  yet  that  it  exercises  a  prejudicial  influence  in  cases  of  nervous  deaf- 
ness, even  when  an  amelioration  has  been  obtained  by  ether. — Glasgow  Mtd. 
Journ.,  July,  1862,  from  Journ.  de  Med.  et  de  Ghirurgie. 

47.  Difficulties  and  Dangers  attending  Catheterism  of  the  Eustachian  Tube. 
— In  a  recent  article  M.  Teiquet  describes  the  principal  difficulties  attending 
catheterism  of  the  Eustachian  tube,  and  the  accidents  to  which  it  may  give  rise. 
Difficulty  may  arise  on  the  part  of  the  patient  from  extreme  timidity,  or  from 
indocility  in  children;  and  both  these  may  necessitate  the  use  of  chloroform. 
Excessive  narrowness  of  the  nasal  fossas  sometimes  requires  the  use  of  a  sound 
of  small  calibre  and  but  slightly  curved,  which  in  such  cases  must  be  introduced 
gently  under  the  lower  turbinated  bone,  with  the  point  directed  towards  the 
external  wall  of  the  fossa.  Sometimes  the  narrowness  is  so  great  that  the 
catheter,  on  reaching  the  middle  of  the  nasal  fossa,  is  arrested,  and  as  it  were 
grasped  between  the  septum  and  the  turbinated  bone,  or  between  the  turbinate 
bone  and  the  upper  jaw.  If  this  be  found  to  occur,  and  the  point  of  the  instru- 
ment, being  in  the  proper  direction,  cannot  advance,  it  must  be  withdrawn,  and 
again  introduced  after  the  patient  has  been  allowed  a  few  minutes'  rest. 

Difficulties  may  also  arise  from  the  configuration  of  the  inferior  nasal  fossa. 
Extreme  narrowness  may  be  caused  by  chronic  inflammatory  thickening  of  the 
mucous  membrane ;  by  polypi  or  fleshy  vegetations ;  by  hypertrophy  of  the 
lower  turbinate  bone,  or  by  greater  or  less  unnatural  elongation  of  the  bone, 
with  a  faulty  direction  of  the  curve ;  by  deviation  of  the  septum  of  the  nasal 
fossa?;  by  exostosis  from  the  ascending  process  of  the  superior  maxillary  bone, 
or  from  the  lower  turbinate  bone.  Extreme  sensibility  of  the  pituitary  mem- 
brane, and  the  pain  produced  by  the  least  touch,  also  constitute  a  serious  diffi- 
culty. Difficulties  may  also  arise  in  the  introduction  of  the  catheter*  from  not 
choosing  a  proper  mode  of  operating,  from  using  a  too  large  or  too  curved 
instrument,  or  from  giving  it  a  wrong  direction.  M.  Triquet  introduces  the 
instrument  directly  into  the  inferior  meatus,  with  the  end  resting  against  the 
external  wall.  If  it  is  gently  carried  on  in  this  direction,  the  point  of  the  instru- 
ment must  infallibly  reach  the  orifice  of  the  Eustachian  tube,  which  lies  imme- 
diately behind  the  inferior  meatus. 

The  accidents  arising  from  the  operation  may  be  local  or  general.    The  local 


1863.] 


Surgery. 


225 


accidents  are:  1.  Laceration  of  the  inferior  part  of  the  nasal  canal.  This  is 
not  of  much  importance;  it  causes  only  slight  pain  and  one  or  two  drops  of 
blood.  2.  Extraordinary  sensibility  of  the  pituitary  membrane  may  render  the 
contact  of  the  catheter  so  painful  as  to  cause  even  the  most  courageous  patient 
to  cry  out.  In  some  persons,  the  contact  of  the  sound  with  the  pituitary  mem- 
brane produces  sneezing.  3.  Another  result  is  excessive  lachrymation.  More 
or  less  lachrymation  very  often  follows  the  first  introduction  of  a  sound  into  the 
nasal  fossae.  Sometimes. the  tears  appear  only  at  the  inner  angle  of  the  eye; 
but  in  lymphatic  children,  in  nervous  females,  and  even  in  impressionable  men, 
the  catheter  scarcely  touches  the  mucous  membrane  before  the  conjunctiva  of 
the  same  side  becomes  rapidly  ingested,  the  eye  becomes  moist  and  is  turned 
upwards,  and  tears  flow  in  abundance.  These  phenomena  are  not  attended  with 
pain,  and  generally  pass  off  in  a  few  seconds.  Nevertheless,  the  possibility  of 
their  occurrence  should  suggest  great  caution  in  employing  catheterism  of  the 
Eustachian  tube  in  persons  subject  to  disease  of  the  eye.  4.  A  few  drops  of 
blood  often  flow  during  the  operation,  probably  from  the  Schneiderian  membrane 
being  grazed  or  lacerated  by  the  end  of  the  instrument.  But  in  subjects  in 
whom,  as  the  result  of  repeated  attacks  of  coryza,  the  mucous  membrane  is  red 
and  inflated,  and,  as  it  were,  studded  with  papillae  full  of  blood,  the  simple  con- 
tact of  the  instrument  may  give  rise  to  a  true  epistaxis,  which  may  always  be 
promptly  arrested  by  the  inspiration  of  a  little  cold  water.  5.  The  operation 
may  be  disturbed  by  a  nervous  cough;  but  this  is  not  of  much  importance.  6. 
As  a  result  of  simple  or  granular  chronic  pharyngitis,  or  of  repeated  quinsy, 
the  tonsils  may  have  remained  hypertrophic d,  and  it  is  not  uncommon  to  meet 
with  a  spasmodic  contraction  of  the  pavilion  of  the  Eustachian  tube,  when  the 
catheter  is  about  to  enter  the  orifice.  In  nervous  subjects,  as  soon  as  the  ca- 
theter touches  the  pituitary  membrane,  the  velum  palati  is  convulsively  drawn 
upwards.  During  these  violent  contractions,  whatever  be  their  cause,  the  peri- 
staphyline  muscles,  inserted  near  the  mouth  of  the  Eustachian  tube,  completely 
effuse  the  opening,  so  that  an  instrument  cannot  pass  it  without  effort.  If  this 
spasmodic  contraction  occurs  only  at  the  moment  when  the  catheter  enters  the 
tube,  the  point  is  expelled  and  falls  into  the  pharynx,  and  the  operation  must 
be  repeated.  7.  If  the  surgeon  employ  too  much  force  to  overcome  the  con- 
traction of  the  muscles,  the  mucous  membrane  may  be  torn,  so  as  to  give  rise 
to  the  production  of  emphysema  at  the  first  attempt  at  deglutition  or  at  inspira- 
tion. If  the  patient  make  a  sudden  movement  of  deglutition,  or  if  the  surgeon 
wish  to  blow  in  a  little  air  for  the  purpose  of  exploring  the  tube,  the  patient  falls 
as  if  struck  by  lightning;  he  raises  his  hand  to  his  neck;  the  eye  is  haggard, 
the  face  congested,  the  mouth  open,  and  the  voice  lost.  The  symptoms  resemble 
those  of  oedema  of  the  glottis  in  its  last  stage.  On  forcibly  drawing  down  the 
tongue  with  the  finger  there  is  perceived  to  be  considerable  emphysema,  raising 
the  whole  of  the  mucous  membrane  of  the  pharynx  and  even  invading  the  larynx, 
especially  the  arytseno-epiglottic  folds.  It  is  requisite  only  to  tear  with  the  nail 
of  the  finger  which  holds  down  the  tongue,  one  of  the  emphysematous  projec- 
tions of  the  mucous  membrane;  the  air  escapes  and  the  patient  recovers.  M. 
Triquet  states  that  death  has  sometimes  occurred  from  this  cause  in  the  practice 
of  London  surgeons.  8.  Rupture  of  the  membrana  tympani,  according  to  M. 
Triquet,  is  liable  to  be  produced  when  air  is  pumped  into  the  Eustachian  tube 
by  means  of  Kramer's  apparatus ;  and  it  may  occur  even  when  simple  insufflation 
with  an  India-rubber  bag  is  employed.  Chronic  inflammation  of  the  membrane 
may  predispose  to  this  accident.  9.  If  too  frequently  repeated,  catheterism  of 
the  Eustachian  tube  irritates  the  mucous  membrane,  and  may  give  rise  to  trau- 
matic inflammation.  But,  sometimes,  even  the  introduction  of  a  small  catheter 
may  give  rise  to  a  painful  inflammation  which  may  extend  to  the  cavity  of  the 
tympanum.  The  general  accidents  that  may  follow  catheterism  of  the  Eusta- 
chian tube  are  :  rigors  and  fever ;  facial  neuralgia ;  obstinate  headache ;  and  an 
increase  of  the  deafness,  or  of  the  noises  in  the  ears,  for  the  relief  of  which  the 
operation  has  been  undertaken.  Suspension  of  the  treatment  is  generally  suffi- 
cient to  arrest  these  accidents. — Dublin  Med.  Press,  Aug.  6,  1862,  from  Gaz. 
des  Hop. 

No.  LXXXIX.— Jan.  1863.  15 


226 


Progress  of  the  Medical  Sciences.  [Jan. 


48.  Double  Inguinal  Hernia  on  the  Same  Side. — Prof.  Engel  states  that  he 
has  in  his  practice  seen  two  instances  of  this  rare  complication.  Both  patients 
were  males;  and  in  both  the  hernias  were  on  the  right  side.  The  internal  hernia 
in  each  case  was  greater  than  the  external.  The  hernias  descended  only  as  far 
as  the  middle  of  the  spermatic  cord,  and  lay  with  their  lower  broad  extremities 
in  close  apposition,  so  that,  until  the  integuments  were  cut  through,  there  was 
nothing  to  denote  the  presence  of  a  double  hernia  ;  the  tumour  appearing  to  be 
an  external  inguinal  hernia.  The  fascia  transversa  that  covered  the  internal 
hernia  was  very  thick,  and  had  a  truly  aponeurotic  appearance. — Brit.  Med. 
Journal,  Feb.  1,  1862,  from  Wiener  Medizin.  Wochen.,  Oct.  5,  1861. 

49.  What  Direction  does  a  Hernial  Sac  take  when  Reduced. — Prof.  Engel 
says  that,  when  an  external  hernia  is  reduced,  there  is  some  trouble  in  pushing  the 
sac  up  through  the  whole  extent  of  the  canal.  The  sac  of  the  internal  hernia, 
on  the  other  hand,  can  be  pushed  with  much  greater  facility  into  the  abdomen, 
and  when  there  does  not  lie  opposite  the  anterior  opening,  but  glides  along  the 
horizontal  branch  of  the  pubic  bone  and  forms  a  peritoneal  pouch,  which  then 
descends  by  the  side  of  the  bladder.  The  sac  of  an  external  hernia  generally 
remains  in  the  neighbourhood  of  the  posterior  opening  of  the  inguinal  canal, 
where  it  throws  the  peritoneum  into  irregular  folds  :  it  only  rarely  forms  a  peri- 
toneal pouch  as  in  internal  inguinal  hernia. — Ibid. 

50.  Metallic  Sutures. — Mr.  W.  N,  Chippeefield,  Staff  Assistant  Surgeon,  Ma- 
dras, reports  (Madras  Quarterly  Journ.  Med.  Sci.,  July,  1862)  very  favourably  of 
metallic  sutures  introduced  into  use  by  our  ingenious  countryman  Dr.  M.  Sims. 
Mr.  0.  says,  "  I  will  not  go  so  far  as  to  say  that  ulceration  never  does  take  place 
in  the  track  of  a  metallic  suture,  because  I  have  seen  a  few  instances  in  which 
it  did  occur.  But  it  may  safely  be  affirmed  that,  as  a  very  general  rule,  there  is 
no  irritation  set  up  by  metallic  sutures  and  that  they  may  be  left  until  the  wound 
has  entirely  healed,  without  any  ulceration  occurring  around  them.  Those  who 
use  these  sutures  must  have  had  numerous  opportunities  of  remarking  the  very 
great  advantage  which  they  possess,  in  this  respect,  over  the  non-metallic  ones. 

"  A  curious  instance  occurred  in  my  practice.  I  used  iron  wire  sutures  to 
close  a  wound  after  removal  of  a  tumour  from  the  back.  When  union  was  com- 
plete I  directed  the  sutures  to  be  removed,  and  the  person  to  whom  the  removal 
was  intrusted  overlooked  one  of  them.  Three  months  afterwards  the  patient 
presented  himself  to  show  that  he  was  quite  cured,  but  just  as  he  was  leaving  the 
room  he  remarked.  '  sometimes  my  skin  feels  irritable,  and  then,  when  I  rub  my 
back,  I  feel  a  sharp  point  like  that  of  a  pin  where  the  wound  was.'  Drawing 
my  ringer  along  the  cicatrix  I  detected  this  sharp  point  and  found  that  it  was 
one  extremity  of  a  suture  which  had  not  been  removed,  the  rest  having,  pro- 
bably, become  imbedded  in  the  few  granulations  which  sprung  up  at  some  points 
before  union  was  complete.  I  drew  upon  the  wire  so  as  to  expose  the  twist, 
divided  and  removed  the  suture  ;  and  ascertained  that,  although  it  had  been  there 
for  three  months,  no  irritation,  ulceration  or  suppuration  had  resulted  from  its 
presence. 

"  When  we  remember  how  many  surgeons  must  have  had  opportunity  of 
noticing  the  very  little  irritation,  if  any,  that  attends  the  circuituous  course 
which  needles  take  when  they  have  been  accidentally  introduced  into  the  body, 
we  can  but  feel  surprise  that  metallic  sutures  did  not  long  ago  come  into  surgi- 
cal use." 

51.  Utility  and  Superiority  of  Metallic  Sutures. — M.  Ollier,  Surgeon  to  the 
Hdtel-Dieu,  Lyon,  terminates  a  series  of  papers  with  the  following  conclusions: 
1.  Metallic  sutures  are  less  irritating  than  those  of  vegetable  or  animal  origin; 
they  divide  the  tissues  less  rapidly,  are  sooner  and  longer  tolerated,  occasion 
less  suppuration  in  their  track,  and  leave  less  apparent  cicatrices.  2.  It  is  not 
only  on  the  results  of  a  great  number  of  operations  in  which  we  have  employed 
these  ligatures  that  we  base  our  statement  of  their  superiority,  but  also  upon 
comparative  experiments  rendered  as  rigorously  exact  as  possible;  the  advan- 
tages possessed  by  the  metallic  sutures  of  the  same  size  over  the  organic  become 


1863.] 


Surgery. 


still  more  striking-  when  the  very  delicate  metallic  threads,  which  we  call  capil- 
lary, are  employed.  3.  The  more  delicate  the  thread  is,  the  less  it  irritates  and 
divides  the  tissues,  this  division  being  the  result  of  ulceration,  and  not  a  mechani- 
cal action ;  in  order  that  this  advantage  be  realized,  the  flaps  must  not  be  sub- 
mitted to  too  violent  traction,  for  pressure  being  then  exerted  on  an  excessively 
narrow  line,  the  thread  acts  in  some  sense  as  a  cutting  instrument:  to  prevent 
this  inconvenience,  the  number  of  sutures  must  be  multiplied,  in  order  to  distri- 
bute the  resistance  over  a  great  number  of  points.  4.  The  superiority  of  the 
metallic  threads  consists  in  the  following  circumstances:  (1),  their  delicacy,  for 
we  may  give  them  the  fineness  of  a  hair,  and  yet  preserve  sufficient  resistance ; 
(2),  the  constancy  of  their  volume,  while  organic  threads  notably  increase  in 
this  through  imbibition  of  the  discharges;  (3),  the  polish  of  their  surfaces  and 
their  impenetrability  by  putrefiable  fluids;  and  (4),  the  fixity  with  which  they 
maintain  the  edges  of  the  wound  in  contact,  while  the  organic  sutures  become 
relaxed  and  float  in  their  track  when  ulceration  has  commenced.  5.  Of  the 
various  metals  from  which  sutures  may  be  made,  iron  is  the  most  suitable,  by 
reason  of  its  greater  tenacity  and  the  facility  with  which  it  may  be  procured; 
by  covering  it  with  an  unoxidizable  metal,  all  the  advantages  are  conferred  on 
iron  which  appertain  to  other  metals,  which  it  might  seem  desirable  to  substi- 
tute for  it  by  reason  of  their  resistance  to  the  reaction  of  organic  liquids.  6. 
For  autoplastic  operations,  iron  threads  of  a  greater  fineness  than  have  hitherto 
been  employed  are  very  suitable;  of  the  delicacy  of  a  hair,  they  still  possess 
sufficient  resistance  to  allow  of  their  being  manipulated  with  safety  and  con- 
venience, while  so  slight  is  the  irritation  which  they  give  rise  to  (being,  so  to 
say,  forgotten  by  the  tissues),  that  they  are  often  tolerated  without  giving  rise 
to  suppuration;  they  may  be  multiplied  without  inconvenience,  and  they  may 
generally  be  employed  without  covering  them  with  gold  or  tin;  when  they  are 
intended  to  remain  long  within  the  tissues  the  iron  should  be  galvanized,  but  in 
no  case  has  their  oxidation  hitherto  given  rise  to  any  serious  inconvenience. 
7.  Metallic  should,  then,  replace  organic  threads  in  all  kinds  of  sutures ;  when 
they  are  fine,  they  are  very  easily  passed  through  the  tissues,  and  can  be  fixed 
by  a  greater  number  of  procedures  than  the  organic  threads ;  their  removal  from 
amidst  the  tissues  in  deep-seated  regions  (as  the  vagina,  velum  of  the  palate, 
&c),  is  the  sole  difficulty  contingent  on  their  employment,  but  this  inconvenience 
cannot  be  considered  as  counterbalancing  their  advantages ;  the  capillary  threads 
are  the  only  ones  which  are  supple  enough  to  admit  of  being  easily  removed.  8. 
It  is  a  useful  practice  to  use  sutures  of  different  sizes  for  different  parts  of  the 
same  wound;  capillary  threads  are  of  great  utility  as  "  perfectioning  sutures"  in 
autoplasty,  when  it  is  our  object  to  obtain  a  perfectly  exact  union  ;  for  some 
operations  large  threads  are  required,  as  "sustaining  sutures,"  to  bring  and  keep 
together  the  base  of  the  flaps,  the  edges  of  which  are  maintained  in  contact  by 
capillary  threads.  9.  Metallic  sutures  may  be  left  longer  within  the  tissues,  and 
they  thus  become  a  precious  resource  in  wounds  which,  uniting  slowly,  require 
that  their  edges  should  be  kept  a  long  time  in  contact.  10.  They  may  be  ad- 
vantageously employed  as  setons  in  small  abscesses  of  the  neck  and  face,  when 
we  wish  to  avoid  producing  visible  cicatrices.  We  may  also  make  use  of  them 
for  the  ligature  of  bloodvessels,  and  they  are  especially  adapted  for  the  opera- 
tion for  varicocele,  allowing  of  the  gradual  division  of  the  venous  agglomeration 
by  a  very  simple  procedure. — Brit,  and  For.  Med.-Chir.  Review,  Oct.  1862, 
from  Gaz.  Hebdom.,  Nos.  9,  12,  17,  23. 

52.  Horsehair  as  a  Substitute  for  Wire  for  Sutures. — Mr.  T.  Smith,  Demon- 
strator of  Anatomy  at  St.  Bartholomew's  Hospital,  states  (Lancet,  Nov.  8, 1862) 
that,  with  a  view  of  finding  a  material  for  sutures  as  unirritating  and  as  unab- 
sorbent  as  wire,  but  more  easy  of  adjustment  and  withdrawal,  he  performed  during 
last  spring  a  series  of  experiments  on  animals  to  determine  the  suitability  of 
horsehair  as  a  substitute  for  wire  in  certain  cases.  The  horsehair  used  was  such 
as  is  ordinarily  sold  by  fishing-tackle  makers.  The  experiments  were  performed 
upon  dogs.  The  general  results  showed  that  there  was  no  appreciable  difference 
shown  by  the  tissues  in  their  tolerance  of  silver  wire  and  horsehair.    Both  ma- 


£28 


Progress  of  the  Medical  Sciences. 


[Jan. 


terials  were  equally  unirritant ;  yet  there  was  a  difference  in  favour  of  horsehair 
in  the  greater  facility  of  its  adjustment  and  subsequent  removal. 

For  the  comparison  between  silk  and  horsehair  as  illustrating  the  relative 
merits  of  the  two  materials  for  sutures,  he  refers  to  the  following  experiments: — 

"June  10th;  1861.  Two  wounds  of  equal  length,  dividing  the  entire  thickness 
of  the  integuments,  were  made  on  opposite  and  corresponding  parts  of  a  dog's 
abdomen ;  four  sutures  were  applied  at  equal  intervals  to  each,  horsehair  being 
used  to  one  wound,  and  fine  ligature  silk  to  the  opposite.  On  the  third  day 
both  wounds  looked  alike  healthy,  and  having  their  edges  in  close  contact.  On 
the  fifth  day  the  edges  of  the  wound  with  silk  sutures  was  slightly  reddened,  and 
pouting  a  little  between  the  points  of  suture;  the  opposite  wound  had  united 
without  suppuration.  On  the  eighth  day  three  out  of  the  four  silk  stitches  had 
cut  their  way  out,  and  the  next  day  the  remaining  one  came  away,  leaving  the 
edges  of  the  wound  just  separated,  but  granulating  healthily.  Three  days  later 
the  wound  had  almost  entirely  healed.  At  this  time  the  opposite  wound  had 
healed  up  soundly  around  the  tracks  of  the  horsehair  sutures,  which  remained 
in  situ,  exciting  no  irritation  whatever,  until  the  dog's  death,  a  month  after  the 
commencement  of  the  experiment. 

"  May  3d.  The  opposite  femoral  arteries  of  a  dog  were  exposed  to  the  same 
extent  just  below  Poupart's  ligament.  Around  the  vessel  on  the  right  lower 
limb  was  passed  a  stout  horsehair,  and  loosely  tied  ;  a  silk  suture  being  similarly 
adjusted  round  the  opposite  artery.  A  month  after  the  operation  the  wound  on 
the  right  side  was  all  but  healed,  and  was  secreting  a  little  serous  discharge. 
At  the  same  time  the  wound  on  the  left  side  was  swollen,  its  edges  were  everted 
and  inflamed,  and  there  was  a  profuse  sanio-purulent  discharge.  Two  days  later 
the  wound  on  the  right  side  had  healed  around  the  track  of  the  horsehair  seton, 
which  was  retained.  While  around  the  silk  on  the  other  side  there  was  profuse 
suppuration  ;  the  surrounding  parts  were  red,  tender,  and  much  swollen ;  and  as 
the  animal's  general  health  was  suffering,  and  it  was  rapidly  emaciating,  the 
silk  was  withdrawn.  The  wound  now  speedily  altered  its  character,  and  by 
June  20th  was  soundly  healed.  September  3d,  four  months  after  its  introduc- 
tion, the  horsehair  still  remained  around  the  right  femoral  artery,  exciting  no 
irritation,  the  parts  being  soundly  healed  around  the  track  of  the  seton. 

"  The  unirritating  nature  of  horsehair  as  a  material  for  suture  is  no  less  marked 
when  applied  to  the  tissues  of  the  human  body.  It  was  used  by  Mr.  Paget  in  a 
case  of  double  entropion,  the  wound  of  the  operation  being  in  one  eyelid  secured 
with  horsehair  sutures,  while  the  opposite  was  brought  together  with  fine  sewing 
cotton.  At  the  end  of  a  week  three  out  of  the  four  cotton  sutures  had  cut  out; 
while  at  the  same  time  all  four  horsehair  sutures  remained  firm. 

"  As  a  material  for  attaching  the  margins  of  the  skin  and  mucous  membrane 
after  circumcision,  or  other  operations  for  phymosis,  I  have  found  horsehair 
most  useful,  having  employed  it  both  in  children  and  adults.  In  one  case  parti- 
cularly, where  a  complete  circumcision  of  the  foreskin,  with  a  free  division  of 
the  mucous  membrane  was  performed  on  a  middle-aged  gentleman,  its  good 
effect  was  remarkable.  Six  sutures  were  introduced,  and  excited  so  little  dis- 
turbance that  the  patient  was  not  kept  for  a  single  day  from  his  business,  which 
involved  pretty  active  exercise.  The  wound  healed  without  suppuration,  and 
though  left  in,  at  the  patient's  request,  some  of  them  for  fourteen  days,  the 
sutures  caused  no  irritation,  and  were  removed  at  last  without  difficulty.  In 
the  removal,  the  advantage  of  horsehair  sutures  over  wire  is  considerable,  since, 
unlike  wire,  which,  after  remaining  a  few  days  in  a  wound,  stiffens  into  a  metallic 
ring,  horsehair,  when  cut  just  aside  the  knot,  either  retaining  its  original  elasti- 
city, springs  open,  or  if  it  has  been  long  soaked  in  the  wound  secretions,  it 
becomes  soft  and  pliable.  I  would  recommend  the  use  of  this  suture  for  wounds 
of  the  eyelid  and  other  parts  of  the  face,  and  to  the  loose  integuments  of  the 
Bcrotum  iiixl  penis;  since  to  all  these  parts  I  have  either  applied  the  suture 
myself  with  good  effect,  or  I  have  seen  it  used  by  others  at  my  suggestion. 

"  But  I  can  imagine  that  there  are  other  uses  to  which  it  might  be  extended, 
and  especially  to  facilitate  the  union  of  wounds  of  the  conjunctiva.  For  the 
purposes  of  suture,  long,  white  tail  hairs  are  the  best.  Before  being  used  they 
should  be  soaked  for  a  minute  or  two  in  water,  or  they  may  be  drawn  once  or 


1863.] 


Surgery. 


229 


twice  through  the  moistened  finger-ends.  The  suture  may  be  fastened  off  in  a 
double  knot,  but  if  the  hair  is  stiff,  a  third  knot  is  often  required.  It  may  be 
removed  in  the  ordinary  manner,  seizing  the  knot  with  the  forceps,  and  dividing 
the  suture  just  aside  of  it.  It  is  scarcely  necessary  to  remark,  that  horsehair, 
as  a  suture,  is  not  suitable  for  wounds  where  there  is  much  tension  between  the 
edges." 

"  P.  S. — Since  writing  the  above  I  have  been  informed  that  the  subject  of 
horsehair  sutures  has  been  treated  of  by  Gustav.  Simon,  but  having  failed  to 
meet  with  the  publication  in  question,  I  am  unable"  to  refer  to  it  more  particu- 
larly." 

53.  Encysted  Tumours. — Dr.  Henley  Thorp  makes  (Dublin  Quarterly  Jour, 
of  Med.  Science,  Feb.  1862)  some  interesting  observations  on  this  subject. 

"  No  surgical  subject,"  he  remarks,  "  possesses  greater  interest  than  the  pa- 
thological history  of  encysted  tumours  generally — the  large  size  they  are  capable 
of  attaining — the  deep  position  they  occasionally  occupy  in  the  visceral  cavities, 
and  their  strange  and  unexpected  contents  invest  these  formations  with  an  in- 
terest not  subordinate  to  that  of  any  others  occurring  in  the  organism.  Although 
the  mode  of  origin  of  growths  such  as  those  produced  in  the  ovaries,  amongst 
the  abdominal  and  pelvic  organs,  at  the  bottom  of  the  orbit,  &c,  cannot  be 
explained  upon  the  principles  long  ago  suggested  by  Sir  A.  Cooper,  the  correct- 
ness of  the  views  of  this  distinguished  surgeon,  as  applied  to  superficial  and 
subtegumentary  wens  and  cysts,  can  scarcely  be  disputed;  various  circumstances 
connected  with  the  pathology  and  symptoms  of  the  tumours  last  referred  to  de- 
monstrate their  character — they  are  not  new  growths,  but  sebaceous  follicles 
distended  into  sacs,  by  reason  of  imperforate  or  obstructed  excretory  orifices, 
and  retained  contents.  Such  swellings  are  commonly  met  with  in  situations 
where  the  sebaceous  glands  are  largest  and  exist  in  greatest  numbers,  e.  g.,  on 
the  head,  face,  and  posterior  aspect  of  the  trunk;  when  small,  they  occupy  a 
position  immediately  under  the  skin,  or  are  closely  connected  with  it ;  on  the 
surface  of  the  tumour,  in  its  early  stage,  and  corresponding  with  the  impervious 
opening  of  the  duct,  a  dark  point  may  often  be  discovered — here  a  probe  can  be 
pushed  into  the  cavity  of  the  follicle,  and  the  contents  expressed;  its  interior  is 
lined  with  a  stratum  of  epithelium  or  thin  cuticle,  and  the  contents,  however 
heterogeneous,  be  they  limpid  as  water,  viscid  as  honey,  pap-like  or  fatty,  pul- 
taceous  or  etheromatous,  hairs  or  horns,  whether  they  present  under  the  micro- 
scope the  appearance  of  epithelial  scales,  perfect  or  disintegrated,  fatty  particles, 
crystallized  or  amorphous  or  other  elements,  they  are  all  the  secreted  products 
of  the  internal  surface  of  the  cyst,  and  correspond  in  every  respect  with  the 
substances  which  a  tegumentary  glandular  follicle  is  capable  of  furnishing. 
Facts  like  these  establish  beyond  all  doubt  the  opinion  of  Sir  A.  Cooper  as  to 
the  follicular  origin  of  encysted  tumours,  when  subcutaneous  or  superficial.  But 
the  fact  of  such  tumours  being  occasionally  congenital — adherent  to  bone — 
occupying  a  position  remote  from  the  skin,  and  separated  from  it  by  a  layer  of 
muscle,  has  opposed  itself  to  the  unexceptional  adoption  of  the  doctrines  enun- 
ciated in  the  Surgical  Essays,  and  has  led  to  the  opinion  that  certain  swellings 
of  this  class,  although  not  far  removed  from  the  surface,  are  nevertheless  adven- 
titious growths — new  formations — differing  essentially  from  the  subcutaneous 
variety.  But  it  does  not  appear  impossible  that  a  body  small  at  first,  and  con- 
nected with  the  skin,  or  even  developed  in  its  substance,  should  as  it  enlarged 
in  size,  come  to  occupy  a  deeper  position,  and  be  detached,  in  process  of  time, 
altogether  from  its  original  connections.  Let  us  suppose  a  cyst,  for  example, 
to  originate  in  the  skin,  covering  the  orbicularis  palpebrarum;  it  enlarges  in  size 
and  presses  backwards,  gradually  the  fibres  of  the  muscle  separate,  and  the 
tumour  passes  through  them  until  the  greater  portion  of  its  bulk  lies  upon  a 
plane  subjacent;  but,  the  tumour  being  globular,  the  action  of  the  muscle  must 
now  of  necessity  tend  to  place  it  in  a  still  deeper  position,  and  finally,  by  reap- 
proximation  of  its  fibres,  to  close  over  and  separate  it  altogether  from  the  cuta- 
neous texture;  imbedded  at  length  in  a  loose  areolar  tissue,  in  close  proximity 
with  the  periosteum  underneath  (which  is  fixed),  and  pressed  upon  in  front  by 
the  muscular  structure  of  the  orbicularis  (which  is  movable),  it  necessarily  con- 


230  Progress  of  the  Medical  Sciences.  [Jan. 


tracts  adhesion  to  the  former.  It  is  no  objection  to  this  explanation  to  say,  that 
encysted  tumours  are  often  congenital — the  same  causes  are  in  operation  during 
intra-uterine  life  as  exist  after  birth — the  skin  is  formed  at  an  early  period  of 
foetal  development,  and  the  sebiparous  glandules  are  in  a  state  of  great  perfec- 
tion and  activity  at  birth — their  orifices  are  probably  as  liable  to  become  ob- 
structed Suring  gestation  as  at  any  other  period  of  existence,  nay  more  so,  from 
anatomical  imperfection — if  the  anus  may  be  congenitally  imperforate  why  should 
a  follicle  not  suffer  from  an  analogous  abnormity  ? 

"  In  practice,  encysted  tumours,  provided  that  they  have  attained  a  certain 
size,  and  have  existed  for  a  moderately  long  period,  will  always  be  found  under- 
lying the  subcutaneous  muscles,  when  these  latter  present  themselves  ;  at  least 
my  own  experience  does  not  furnish  an  example  to  the  contrary;  and,  when  a 
bone  lies  near,  they  are  very  proue  to  contract  an  adhesion  to  it,  and  indent  its 
surface.  No  doubt  the  common  wen,  when  it  occupies  the  higher  regions  of  the 
head,  seldom  attaches  itself  to  the  pericranium,  a  fact  readily  explained  by  the 
mobility  of  the  scalp  in  which  it  is  imbedded,  and  the  intervention  of  the  epi- 
cranial aponeurosis,  the  motions  of  which  it  is  compelled  to  follow,  but  within 
and  about  the  orbit  and  frontal  region,  where  no  such  structure  separates  the 
tumour  from  the  fibrous  covering  of  the  bone,  the  two  will  be  found  more  or  less 
intimately  adherent. 

''Although  the  majority  of  encysted  tumours  of  the  orbital  region  belong  to 
the  variety  technically  called  hygroma — 'thin  cysts  with  watery  contents — it  is 
not  to  be  supposed  that  this  locality  is  not  obnoxious  to  other  descriptions  of 
these  swellings.  The  second  case  detailed  in  this  communication  was  an  example 
of  etheroma,  and  the  sac  possessed  by  no  means  an  inconsiderable  degree  of 
strength  and  thickness.  In  cases  Nos.  3  and  4  the  integuments  presented  quite 
a  natural  appearance.  In  the  third  case  the  tumour  was  not  adherent.  In  one 
of  the  patients,  the  swelling  was  more  globular  than  oval  ;  and  in  the  girl  Mack- 
lin  the  cyst  had  an  irregular  outline,  and  contained,  not  a  fluid,  but  a  suet-like 
substance,  calcareous  matter,  and  hairs.  The  conclusion,  therefore,  forced  upon 
me  is,  that  encysted  tumours  in  the  neighbourhood  of  the  orbit  do  not  possess 
peculiarities,  although  they  frequently  differ  in  many  respects  from  congenerous 
swellings  of  the  head  and  face. 

"In  all  operations  which  interest  surfaces  so  much  exposed  to  view  as  the 
eyelids  and  parts  adjacent,  a  point  of  no  inconsiderable  importance  is  the  avoid- 
ance of  unsightly  scars  and  cicatrices ;  all  incisions  here  should,  if  possible,  be 
parallel  to  the  natural  folds  and  ridges  of  the  skin.  I  have  never  found  it  neces- 
sary to  deviate  from  this  principle,  nor  have  I  ever  met  with  a  case  requiring  a 
crucial  incision;  certainly  a  vertical  division  of  the  lid  should  not  be  practised 
if  at  all  avoidable. 

"Although  in  removing  the  tumour  great  caution  is  necessary  to  avoid  an 
opening,  it  may  be  advantageous,  on  certain  occasions,  after  the  cyst  has  been 
for  the  greater  part  isolated  (as  when  the  bone  is  deeply  indented,  or  the  tumour 
sinks  far  into  the  orbital  cavity),  to  permit  a  portion  of  the  contents  to  escape 
through  a  small  puncture,  the  partial  collapse  of  the  sac  will  diminish  its  size, 
and  thus  permit  a  more  distinct  view  of  its  deep-seated  attachments.  In  the 
first  case  referred  to  it  would  have  been  perfectly  impossible  to  effect  the  sepa- 
ration of  the  tumour  from  the  roof  of  the  orbit,  were  not  this  expedient  adopted. 

"  After  the  operation  sutures  are  indispensable ;  the  edges  of  the  wound,  from 
want  of  due  support,  have  a  great  tendency  to  become  inverted ;  a  few  interrupted 
stitches  made  with  a  slender  sewing-needle  and  fine  waxed  thread,  with  strips  of 
court-plaster  at  intervals,  supported  by  a  well-adjusted  compress,  offer  the  best 
means  of  insuring  an  accurate  union ;  as  for  metallic  ligatures,  I  have  almost 
renounced  them,  and  I  am  not  ashamed  to  confess  the  heresy. 

"In  cases  where  the  total  extirpation  of  the  tumour  is  impossible,  from  its 
deep  position  or  intimate  connection  with  important  organs,  a  secondary  growth 
is  very  liable,  in  process  of  time,  to  make  its  appearance.  The  tumour  is  said 
to  '  grow  again ;'  but  this  language  is  inaccurate :  no  doubt  a  swelling  does  grow, 
but  it  is  an  adventitious  one,  engrafted  upon  the  remnant  of  the  former  cyst, 
which,  continuing  to  perform  its  function  as  a  secreting  surface,  furnishes  an 
unorganized  product  that  acts  as  a  foreign  body,  round  which  the  cellular  tissue 


1863.] 


Surgery. 


231 


solidifies  into  a  sac.  It  is  thus  relapses  occur,  and  hence  the  advantage  of  being 
able  to  remove  every  portion  of  the  tumour.  When  seated  in  the  orbit,  if  deeply 
rooted,  a  cystic  growth  is  one  of  very  serious  import,  and  may  easily  be  con- 
founded with  other  causes  of  exophthalmos;1  nor  is  laying  open  the  sac,  and 
exciting  a  suppurative  action  unattended  with  danger.  We  must  recollect  that 
the  periosteum  of  the  orbit  is  continuous  with  the  dura  mater;  and  further,  that 
a  delicate  sheath  of  the  subarachnoid  cellular  tissue  is  continued  forward  around 
the  bloodvessels  and  nerves  that  enter  posteriorly ;  moreover,  that  the  ophthal- 
mic is  in  communication  with  the  cerebral  veins  through  the  cavernous  and  other 
sinuses.  Inflammation  may  readily  extend  by  any  of  these  routes  from  the 
orbital  cavity  to  the  brain  and  its  membranes ;  nor  is  this  occurrence  by  any 
means  rare.  Mackenzie,  Wardrop,  and  other  ophthalmic  surgeons  give  cases. 
When  I  read  of  encysted  tumours  frequently  operated  upon,  both  in  London  and 
Dublin,  before  a  radical  cure  could  be  effected,  I  may  be  permitted  to  congratu- 
late myself  at  being  more  fortunate  with  my  cases." 

54.  Fibrous  Tumours  of  the  Iliac  Fossa. — In  some  clinical  remarks  on  a  case 
under  his  care,  in  the  H6pital  des  Cliniques,  M.  Nelaton  took  occasion  to  de- 
scribe a  form  of  tumour,  of  which  he  has  met  with  fifteen  or  twenty  instances 
in  the  course  of  his  practice.  In  structure,  these  tumours  are  composed  of 
tissue  resembling  that  which  constitutes  fibrous  tumours  of  the  uterus ;  their 
constant  point  of  attachment  or  origin  is  the  crest  of  the  ilium,  near  the  antero- 
superior  spine  of  the  bone.  They  are  developed  in  the  subperitoneal  cellular 
tissue,  behind  the  inguinal  canal,  between  the  iliac  fascia  and  the  peritoneum. 
M.  Nelaton  has  found  these  tumours  in  females  only;  and  all  the  patients  in 
whom  he  has  found  them  had  borne  children.  They  may  be  connected,  to  some 
extent,  with  the  congestion  which  so  frequently  occurs  at  the  menstrual  periods 
and  during  pregnancy.  The  progress  of  these  tumours  is  generally  very  slow; 
they  take  from  four  to  ten  years  in  gaining  the  size  of  two  fists.  The  largest 
which  M.  Nelaton  has  seen,  was  of  the  size  of  a  foetus  at  full  term. 

The  fibrous  tumours  may  be  confounded  with  enchondromatous  tumours,  or 
with  intestinal  enlargements  from  impacted  feces.  But  enchondroma  is  very 
hard  knobbed ;  while  the  fibrous  tumour  is  smooth,  and  is  not  attended  by  dis- 
order of  the  intestines.  Again,  the  fibrous  tumours  may  be  confounded  with 
swellings,  resulting  from  glandular  degeneration  or  hypertrophy,  with  fibrous 
tumours  of  the  uterus  projecting  into  one  o^the  iliac  fossse,  or  with  tumours  of 
syphilitic  origin.  Tumours  of  the  latter  kind,  appearing  among  tertiary  symp- 
toms, have  a  certain  amount  of  resemblance  to  the  fibrous  tumours  of  the  iliac 
fossa.  But  the  integument  covering  them  is  generally  slightly  changed  in 
colour,  and  the  subcutaneous  tissue  is  found,  on  pressure  for  about  a  minute,  to 
be  a  little  cedematous ;  while  nothing  of  the  kind  is  observed  in  the  fibrous 
tumours.  Glandular  swellings  have  not  the  firmness  which  characterizes  the 
fibrous  tumours;  they  are  somewhat  resistent  to  the  touch,  and  sometimes  mani- 
fest obscure  fluctuation;  and  (a  valuable  point  in  diagnosis)  they  are  scarcely 
ever  solitary,  while  the  fibrous  tumours  of  the  iliac  fossa  are  always  so.  More- 
over, glandular  swellings  are  situated  at  the  level  of  the  inguino-crural  fold, 
rarely  in  the  iliac  fossa ;  and  they  are  movable  in  every  direction.  Fibrous 
tumours  of  the  uterus  are  distinguished  by  being  readily  moved  through  the 
abdominal  walls  and  the  vagina ;  while  the  fibrous  tumours  on  the  ilium  remain 
fixed  when  palpation  is  attempted. 

With  regard  to  treatment,  M.  Nelaton  advises  that,  if  the  tumour  be  small, 
and  do  not  cause  much  pain  or  inconvenience,  the  surgeon  should  not  be  in  a 
hurry  to  interfere  with  it.  But  if  it  become  painful  and  grow  rapidly,  or  if  the 
patient  insist  strongly  on  its  removal,  an  operation  must  be  performed.  M. 


1  Several  years  ago  a  case  of  exophthalmos  was  admitted  into  the  City  of  Dublin 
Hospital,  under  the  care  of  Dr.  Jacob.  The  eyeball  was  greatly  protruded,  the 
cornea  dull,  and  the  lids  congested  and  of  a  purplish  colour.  It  was  decided  to 
extirpate  the  globe,  and  afterwards  to  remove  the  contents  of  the  orbit,  if  necessary. 
The  first  incision  at  the  outer  canthus  opened  a  cyst,  which  immediately  emptied 
itself,  and  permitted  the  eye  to  resume  its  usual  position. 


232  Progress  of  the  Medical  Sciences.  [Jan. 


Nelaton  lias  operated  in  two  instances.  In  one  case,  M.  Michou,  under  whose 
care  the  patient  was,  believed  the  disease  to  be  encephaloid  ;  M.  N61aton,  how- 
ever, recommended  its  removal,  to  which  M.  Michou  consented.  The  perito- 
neum was  strongly  adherent  to  the  tumour,  and  a  small  hole  was  torn  in  it, 
which,  however,  was  closed  by  a  portion  of  epiploon.  The  large  vessels  in  the 
iliac  region  were  exposed,  but  none  were  wounded.  The  pedicle  of  the  tumour 
was  cut  from  the  crest  of  the  ilium  by  scissors.  M.  Nelaton  saw  the  patient 
lately  (four  or  five  years  after  the  operation),  and  she  remained  perfectly  well. 
The  second  case  was  more  simple  :  in  it  a  tumour,  rather  larger  than  the  head 
of  a  foetus  at  full  term,  was  removed  through  an  incision  of  the  same  kind  as 
that  made  for  ligature  of  the  external  iliac  artery.  The  patient  recovered,  and 
there  has  been  no  relapse. — Brit.  Med.  Journ.,  March  29,  1862,  from  Gaz.  des 
HOpilaux,  Feb.  18,  1862. 

55.  Necrosis. — Mr.  Thos.  Wormald,  Surgeon  to  St.  Bartholomew's  Hospital, 
presents  (Lancet,  Oct.  25,  1862)  some  interesting  remarks  on  this  subject. 

"When  a  portion  of  bone  dies,"  he  observes,  "the  means  by  which  nature 
gets  rid  of  it  has  been  a  subject  of  controversy,  and  hitherto  I  think  the  truth 
has  not  appeared. 

"The  late  Mr.  Bransby  Cooper,  in  his  Lectures,  has  shown  that  where  there  is 
dead  bone  the  'necrotic'  pus  discharged  contains  much  phosphate  of  lime;  in 
ordinary  pus  there  is  scarcely  a  trace  to  be  found. 

"  From  observations  and  experiments  I  have  long  concluded  that  it  must  be 
through  chemical  agencies  the  disintegration  of  dead  bone  is  accomplished. 

"In  necrosis  pus  is  secreted  abundantly,  and  it  is  alkaline.  Presently  acid  is 
•produced,  which  is  at  first  weak,  but  it  becomes  stronger,  and  in  some  cases  it 
may  be  seen  exuding  through  minute  apertures,  which  gradually  enlarge  until 
they  are  quite  visible,  and  the  surface  of  the  dead  bone  becomes  rough. 

"In  necrosis,  by  the  use  of  common  litmus  paper  an  acid  may  be  detected. 
Mr.  Attfield,  demonstrator  of  practical  chemistry  at  St.  Bartholomew's  Hospital, 
found  the  acid  taken  from  the  surface  of  a  dead  bone  to  be  phosphoric;  this 
dissolves  the  bone,  and  the  air-bubbles  resulting  may  be  seen  on  the  surface  of 
the  pus. 

"It  may  be  further  observed  that  in  doubtful  cases  of  necrosis  the  presence 
of  phosphoric  acid  may  prove  a  valuable  diagnosis;  and  in  cases  where  dead 
bone  cannot  be  removed  by  operation  Nature  seems  to  indicate  an  appropriate 
remedy." 

56.  Ovariotomy. —  [Dr.  Eobert  Lee  read  a  paper  recently  (Nov.  11,  1862) 
on  this  subject,  before  the  Royal  Medical  and  Chirurgical  Society,  which  gave 
rise  to  an  animated  discussion.  As  the  subject  is  one  of  great  interest,  and  the 
debate  shows  the  opinions  of  the  leading  surgeons  of  London  in  regard  to  the 
operation,  we  give  it  in  full,  though  we  must  say  that  we  do  not  see  that  much 
new  light  is  shed  upon  the  question.  The  discussion  seems  to  us  not  to  have 
been  conducted  in  a  true  philosophical  spirit,  but  the  advocates  for  the  opera- 
tion and  its  opponents  each  have  engaged  in  it  as  partisans;  the  former  greatly 
overvaluing,  and  the  latter  underrating,  its  results.  The  great  question — the 
means  pf  diagnosing  the  cases  suitable  for  an  operation — has  not  been  eluci- 
da1  ed  ;  and,  until  that  is  done,  the  operation  must  be  regarded  with  some  distrust. 
We  learn  from  reliable  authority,  that  one  of  our  most  experienced  ovarioto- 
mies operated  a  few  months  since  upon  a  lady  whom  he  pronounced  to  have 
ovarian  disease,  and  that  the  diagnosis  was  as  clear  and  certain  as  in  any  case 
he  had  ever  examined;  yet,  when  the  operation  was  performed,  the  disease 
proved  to  be  a  fibrous  tumour  of  the  uterus;  and  it  was  not  until  after  the 
tumour  had  been  excised  and  carefully  examined  that  the  mistake  was  dis- 
covered.] 

Dr.  Lke  briefly  states  that  his  experience  during  the  last  eleven  years,  in  re- 
gard to  ovarian  disease,  convinces  him  that  the  published  records  of  ovariotomy 
do  not  truthfully  represent  the  statistics  of  the  operation;  successful  cases  hav- 
ing been  made  known,  and  the  unsuccessful  ones  kept  in  the  background.  In 
none  of  the  cases  which  have  occurred  under  his  own  eye  has  he  thought  it 


1863.] 


Surgery. 


233 


right  to  recommend  the  operation ;  and  he  considers  the  slow  progress  made  by 
many  of  the  cases  to  have  been  a  justification  of  the  course  pursued  by  him. 

The  President  said  that,  fifteen  years  ago,  he  saw  Mr.  Walne  perform  ovari- 
otomy, in  a  woman  29  years  of  age.  He  made  the  large  incision.  The  patient 
recovered,  and  was  well  now. 

Dr.  Tyler  Smith  said  that,  for  twenty  years,  he  had,  as  Dr.  Eobert  Lee  still 
did,  recommended  that  cases  of  ovarian  dropsy  should  either  be  let  alone,  or  be 
treated  by  palliative  means,  as  tapping,  etc.  He  then  conscientiously  believed 
that  he  was  doing  more  good  by  these  palliative  measures  than  by  ovariotomy. 
He  saw,  however,  much  misery  and  many  miserable  deaths  from  this  disease. 
One  case,  especially,  led  him  to  consider  ovariotomy  in  a  more  favourable  light. 
Three  years  ago,  he  saw  a  case  of  Dr.  Lee's  which  he  considered  favourable  for 
ovariotomy.  Dr.  Lee  thought  him  a  madman  for  entertaining  such  an  idea. 
The  sudden  death  of  this  patient  made  him  resolve,  in  the  next  favourable  case, 
to  try  ovariotomy.  He  had  since  done  the  operation  in  fourteen  cases.  He  had 
not  rejected  a  single  case.  As  regards  diagnosis,  of  which  the  author  had  spoken 
in  his  paper,  he  would  add,  that  in  some  of  these  cases  Dr.  Lee's  diagnosis  had 
been  wrong.  No  one  could  be  infallible  in  diagnosis,  but,  for  the  last  three 
years,  he  had  made  but  one  mistake.  With  this  exception,  all  the  cases  ope- 
rated on  were  ovarian.  In  this  case,  which  was  one  of  cancerous  disease  of  the 
mesentery,  he  had  been  unable  to  complete  the  operation,  and  the  patient  died 
in  twenty-four  hours.  The  patient  was,  at  the  time  of  the  operation,  then  in 
danger  of  death.  Of  the  fourteen  cases,  three  had  died,  and — except  one,  done 
on  Friday  week,  which  was  going  on  well — all  the  others  were  now  well.  So  that 
of  fourteen  cases,  three  were  dead,  eleven  cured,  and  there  was  one  mistake. 
He  would  ask  the  author  if  he  had  had  equally  good  results  from  his  do-nothing 
practice.  If  so,  his  results  were  different  to  those  he  (Dr.  Tyler  Smith)  had 
obtained  before  he  adopted  ovariotomy.  He  hoped  that,  some  time,  the  whole 
statistics  of  ovariotomy  would  be  published.  He  thought  that  the  operation 
was  safer,  easier,  and  less  dangerous  than  it  was  believed  to  be ;  and  that  .the 
chief  danger  arose  from  medical  men  like  Dr.  Lee,  whose  recommendation  in- 
duced the  patient  to  put  it  off.  He  (Dr.  Tyler  Smith)  thought,  however,  that 
we  should  not  operate  until  the  patient's  health  had  begun  to  fail ;  but,  in  some 
cases,  the  patient  insisted  on  the  operation.  We  have  to  deal  with  minds  as 
well  as  with  bodies,  and  patients  often  will  not  endure  a  life  of  uncertainty.  In 
conclusion,  he  would  add  that  Dr.  Lee  had  not  brought  forward  anything  against 
the  operation,  and  that  the  hundreds  of  women  saved  by  ovariotomy  would 
have  a  stronger  influence  than  his  mere  dictum.  Two  of  the  cases  on  which 
he  had  operated  had  been  patients  of  Dr.  Lee,  who  strenuously  opposed  the 
operation. 

In  reply  to  Dr.  Beaman,  Dr.  Tyler  Smith  said  that  the  two  patients  of  Dr. 
Lee,  referred  to  in  his  concluding  remarks,  recovered. 

Mr.  Spencer  Wells  regretted  that  the  substance  of  the  documents  accom- 
panying Dr.  Lee's  paper  had  not  been  made  known  to  the  meeting,  because  the 
portion  of  the  paper  which  had  been  read  contained  neither  facts  nor  arguments, 
and  all  that  any  one  could  do,  by  way  of  reply,  was  to  endeavour  to  prove  that 
Dr.  Lee's  objections  to  ovariotomy  should  not  lead  to  the  condemnation  of  the 
operation.  Three  principal  objections  were  stated  by  Dr.  Lee.  He  said  that 
women  suffering  from  ovarian  disease  may  live  for  a  long  time  under  palliative 
treatment;  secondly,  that  it  is  often  impossible  to  determine  whether  a  tumour 
be  really  ovarian,  and,  if  so,  whether  it  can  be  removed;  and,  lastly,  that  ova- 
riotomy is  a  much  more  dangerous  operation  than  published  statistics  would  lead 
us  to  believe.  In  reply  to  the  first  of  these  objections,  it  would  be  admitted  by 
every  one  who  had  followed  a  case  of  ovarian  disease  to  its  natural  or  ordinary 
termination,  that  it  was  difficult  to  imagine  a  life  of  more  hopeless  misery ;  and 
that  nothing  could  be  more  painful  than  to  watch,  day  by  day,  a  poor  creature 
who,  for  some  reason,  was  beyond  the  aid  of  surgery,  sinking  into  her  grave, 
worn  out  by  protracted  suffering.  Yet  this  was  the  fate  to  which  Dr.  Lee  would 
condemn  hundreds  of  poor  women  who  might  be  restored  to  perfect  health  by 
ovariotomy.  Then  as  to  the  alleged  difficulty  of  diagnosis,  and  the  distressing 
mistakes  which  had  been  recorded,  it  must  be  acknowledged  that  these  mistakes 


234 


Progress  of  the  Medical  Sciences. 


[Jan. 


were  errors  of  a  bygone  age.  It  would  be  almost  impossible  for  any  one  ac- 
quainted with  the  ordinary  practice  of  percussion  to  repeat  the  error  of  the 
earliest  Scotch  ovariotomist,  and  open  the  abdomen  of  a  woman  whose  only 
tumour  was  formed  by  flatulent  distension  of  the  intestines.  Nor  could  any  one 
who  had  ever  heard  the  placental  murmur,  or  the  sounds  of  the  foetal  heart,  re- 
peat mistakes  which  had  been  made  in  the  later  stages  of  pregnancy.  In  the 
earlier  periods  of  pregnancy,  doubts  would  sometimes  arise;  and  in  cases  where 
ovarian  disease  complicated  pregnancy,  an  occasional  error  might  be  unavoida- 
ble ;  but,  in  the  great  majority  of  cases,  the  diagnosis  of  ovarian  disease  might 
be  brought  as  near  to  a  positive  certainty  as  could  reasonably  be  hoped  for  in 
any  department  of  surgery.  From  his  (Mr.  Wells's)  own  experience  of  forty- 
six  cases  in  which  he  had  performed  ovariotomy,  of  six  others  in  which  he  had 
commenced  the  operation,  or  had  made  an  exploratory  incision,  and  of  very  many 
in  which  he  had  either  simply  tapped,  or  had  injected  iodine,  he  should  say  that 
the  diagnosis  was  generally  easy;  and  though,  in  some  rare  cases,  it  was  not  so, 
yet  no  important  mistake  had  been  made  in  any  one  of  these  cases.  This  alone 
was  enough  to  prove  that  any  supposed  difficulty  in  diagnosis  could  not  be  main- 
tained as  an  objection  to  ovariotomy ;  and  the  only  logical  conclusion  which 
could  be  drawn  from  the  mistakes  due  to  the  gross  ignorance  or  gross  careless- 
ness of  some  surgeons,  or  from  the  very  rare  errors  which  might  be  unavoidable 
to  the  most  careful  and  the  best  instructed,  was  not  the  condemnation  of  a  useful 
operation,  but  the  endeavour  so  to  improve  our  means  of  diagnosis  as  to  make 
errors  less  and  less  excusable.  In  no  other  department  of  surgery  would  the 
possibility  of  an  occasional  mistake  lead  to  the  abandonment  of  all  surgical  in- 
terference, and  it  would  be  quite  as  logical  to  decry  lithotomy  because  a  neither 
careless  nor  incompetent  surgeon  might  possibly  cut  into  a  bladder  which  did 
not  contain  a  stone ;  or  to  condemn  the  ligature  of  arteries,  because  some  one 
had  tied  an  artery  to  cure  an  aneurism  which  did  not  exist ;  or  to  raise  an  out- 
cry against  the  excision  of  joints,  because  a  joint  had  been  cut  out  which  ap- 
peared to  be  so  little  diseased  that  a  few  weeks'  rest  would  have  saved  the  limb 
— as  to  denounce  ovariotomy  because  some  surgeons  who  had  performed  it  had 
made  mistakes.  Then,  as  to  the  mortality — undoubtedly  it  was  high;  but  it 
was  high  because  we  are  often  driven  to  operate  in  cases  where  the  patient  has 
been  so  broken  down  by  the  disease  that  the  hope  of  success  is  very  faint.  If 
only  favourable  cases  were  operated  on,  a  very  large  proportion  would  recover. 
We  were  now  gaining  the  knowledge  which  enabled  us  to  say  to  a  patient,  "The 
chances  are  ten  to  one,  or  five  to  one,  or  two  to  one,  against  you  ;  or,  the  chances 
of  success  and  failure  are  about  equal ;  or,  they  are  two  to  one,  or  five  to  one, 
or  ten  to  one  in  your  favour."  Out  of  his  (Mr.  Wells's)  own  46  cases,  17  had 
died  and  29  had  recovered,  but  many  of  them  were  very  desperate  cases;  and 
he  could  say  that  he  had  scarcely  ever  lost  a  patient  when  he  had  felt  very  con- 
fident of  success  before  the  operation.  Ten  out  of  the  last  eleven  cases  had 
recovered.  But  it  is  said  that  the  mortality  is  greater  than  the  profession  believe, 
because  unsuccessful  cases  are  concealed.  This  might  be  said  of  every  other 
surgical  operation.  Men  take  pride  and  pleasure  in  their  successes,  and  remem- 
ber them,  and  make  them  known;  while  their  reverses  have  often  been  so  painful 
that  they  try  to  forget  them.  At  any  rate,  they  do  not  publish  them,  unless, 
for  some  special  reason,  they  feel  bound  to  do  so.  So  in  estimating  the  mor- 
tality of  every  operation — lithotomy,  amputations,  herniotomy,  and  so  on — it  is 
always  necessary  to  make  some  allowance  for  probable  error,  due  to  the  non- 
publication  of  unsuccessful  cases  ;  but,  with  regard  to  ovariotomy,  so  much 
attention  had  been  directed  towards  it,  that  we.  probably  had  a  larger  propor- 
tion of  cases  published,  compared  to  the  number  of  operations  performed,  than 
could  be  collected  respecting  any  other  operation.  He  (Mr.  Wells)  knew  that 
none  of  his  own  cases  had  been  kept  back ;  he  fully  believed  that  many  other 
operators  had  been  equally  truthful;  and  he  would  join  most  warmly  with  Dr. 
Lee  in  denouncing  the  conduct  of  any  man  who  could  bring  forward  his  suc- 
cessful cases  and  keep  his  fatal  cases  wholly  or  partly  concealed.  No  punish- 
ment could  be  too  severe  for  such  flagrant  dishonesty.  But  it  was  a  libel  on 
the  profession  to  suppose  that  such  an  offence  was  common  enough  to  throw  dis- 
credit upon  an  operation  which  had  done  honour  to  English  surgery.    The  Jury 


1863.] 


Surgery. 


235 


on  Surgical  Instruments  in  the  International  Exhibition  have  published  their 
report — and  a  most  able  report  it  is ;  just  what  one  would  expect  from  the  emi- 
nent men  who  compose  the  jury — and  among  "the  most  remarkable  additions  to 
general  surgery  since  1851,  which  receive  illustration  in  the  present  exhibition," 
the  jury  thus  speak  of  ovariotomy :  "  Described  by  De  Haen  as  an  operation  of 
which  it  would  not  do  to  talk,  lest  some  reckless  surgeon  should  attempt  its  per- 
formance; and  by  Scanzoni  as  a  proof  of  madness  in  the  patient  who  should 
adopt,  and  of  crime  in  the  surgeon  who  should  abet,  such  a  mode  of  suicide ; 
and,  again,  energetically  denounced  by  Yelpeau  as  an  operation  on  no  account 
to  be  admitted  into  French  surgery — it  is  a  source  of  legitimate  satisfaction  to 
English  surgeons,  from  William  Hunter  downwards,  that,  thanks  to  their  per- 
ception of  the  conditions  necessary  to  success,  and  their  courageous  self-reliance 
in  the  face  of  difficulty,  an  operation  which,  till  lately,  was  considered  scarcely 
admissible,  should  now  be  practised  with  results  at  least  as  favourable  as  attend 
many  other  capital  operations."  This  "  source  of  legitimate  satisfaction  to 
English  surgeons,"  Dr.  Lee  would  deny  them ;  but  it  was  to  be  hoped  that  the 
Society,  so  far  from  aiding  him,  would,  on  the  contrary,  influence  professional 
opinion  in  favour  of  an  operation  which  should  rank  among  the  greatest  benefits 
conferred  by  surgery  upon  mankind. 

Dr.  Savage  said  that,  as  senior  physician  of  the  Samaritan  Hospital,  he  had 
seen  nearly  all  the  cases  operated  upon,  in  that  institution,  by  Mr.  Spencer 
Wells,  and,  like  Dr.  Lee,  had  also  got  together  a  list  of  cases  of  ovariotomy; 
but  his  collection  differed  from  Dr.  Lee's  in  one  important  point.  Dr.  Lee  never 
would  see  the  operation  done.  He  (Dr.  Savage)  had  asked  him  to  come  and  see 
a  case,  but  Dr.  Lee  said  he  would  rather  not.  This  reminded  him  of  an  anato- 
mist who  denied  the  existence  of  the  curling  arteries  of  the  uterus.  Many  years 
ago,  when  Dr.  Savage  was  giving  some  attention  to  this  point,  he  one  day  asked 
this  gentleman  to  come  and  see  these  arteries  in  a  uterine  perforation,  but  he 
said,  ''No;  he  had  said  there  were  no  such  arteries,  and  he  did  not  want  to  see 
them."  Dr.  Lee  stood  precisely  in  this  same  position.  He  had  expressed  strong 
opinions  against  ovariotomy,  and  he  did  "not  want"  to  see  anything  which  could 
alter  his  opinions.  So  his  list  of  cases  of  ovariotomy,  though  large,  was  perhaps 
less  reliable  than  his  (Dr.  Savage's),  though  only  numbering  between  fifty  and 
sixty,  because  he  (Dr.  Savage)  had  taken  care  to  become  intimately  acquainted 
with  each  case  before  the  operation,  during  the  operation,  and  after  the  opera- 
tion. Thus,  his  personal  information  being  more  precise,  might,  perhaps,  be 
accepted  as  making  up  for  deficiency  in  numbers  so  far  as  to  justify  his  offering 
a  few  remarks  on  the  present  question.  When  Mr.  Spencer  Wells  became  his 
colleague  at  the  Samaritan  Hospital,  the  authorities  there,  himself  included,  on 
the  whole,  were  unfavourable  to  ovariotomy ;  but  Mr.  Wells's  success  was  de- 
cisive. Like  -Dr.  Smith,  he  (Dr.  Savage)  could  not  help  becoming  a  convert, 
but  he  could  not  agree  in  considering  the  extirpation  of  a  diseased  overy  a  simple 
operation ;  quite  the  contrary.  It  seemed  to  him  there  was  no  operation  which 
could  present  a  greater  source  of  embarrassment,  or  required  more  presence  of 
mind,  readiness  in  resource,  and  the  other  best  qualities  of  the  surgeon.  The 
reasons  just  advanced  by  Dr.  Smith  and  Mr.  Spencer  Wells,  in  favour  of  ova- 
riotomy, must  be  concurred  in  sooner  or  later,  especially  by  those  who  had  been 
in  the  melancholy  situation  of  witnessing  the  progress  and  termination  even  of 
ordinary  forms  of  ovarian  disease.  It  had  been  noticed  that  the  operation  had 
been  followed  by  an  inequality  of  success,  in  regard  to  persons  and  places,  which 
had  excited  a  doubt,  not  only  whether  it  could  ever  be  brought  under  definite 
surgical  rules,  but  whether  individual  statements  of  successful  cases  could  be 
relied  on.  From  his  own  observation,  he  could  not  help  thinking  that  very  much 
depended,  not  so  much  on  the  skill,  as  on  the  experience,  of  the  operator.  For 
instance,  what  course  would  an  inexperienced  operator  adopt  in  a  case  where, 
the  tumour  having  been  freed  from  the  abdominal  cavity  in  the  most  skilful 
manner,  everything  promising  its  speedy  aiid  successful  separation,  he  could  not 
find  a  pedicle — no  place  to  apply  any  form  of  ligature  ?  Would  any  one,  with- 
out some  experience  in  such  operations,  be  ready  with  a  suitable  expedient  for 
such  a  complication?  Yet  he  had  lately  been  present  when  this  occurred  to 
Mr.  Wells,  and  the  measures  resorted  to  were  followed  by  one  of  the  best  reco- 


Progress  of  the  Medical  Sciences.  [Jan. 


veries.  One  of  Dr.  Lee's  chief  objections  turned  on  the  presumed  insuperable 
difficulty  of  making  out  satisfactorily,  in  any  given  case,  whether  or  not  the 
tumour  was  a  pregnant  uterus,  or  whether  pregnancy  coexisted.  This  difficulty 
had  not  led  to  any  mistake  in  any  of  the  cases  he  had  seen,  nor  could  he  imagine 
how  it  need  be  made.  Fluctuation  in  many  compound  cysts  was  avowedly  very 
obscure,  and  the  abdomen,  to  the  sight  and  touch,  often  closely  resembled  its 
appearance  in  pregnancy,  but  the  usual  modes  of  investigation  were  quite  suffi- 
cient to  make  out  a  correct  diagnosis  in  every  case.  He  had  come  to  this  meet- 
ing of  the  Society  in  the  anticipation  of  hearing  sundry  other  points  of  difficulty 
connected  with  ovarian  diagnosis  discussed;  but  as  what  had  transpired  of  Dr. 
Lee's  communication  offered  no  precise  fact  of  any  kind  whatever,  there  was 
nothing  to  deal  with.  Dr.  Lee  had  included  in  his  list  all  the  cases  of  ovariotomy 
he  could  get  at.  Well,  then,  the  case  he  was  about  to  allude  to  must  be  one  of 
them,  and,  therefore,  before  the  Society,  and  he  thought  it  would  be  satisfactory 
to  the  profession  if  they  were  informed  what  were  the  precise  points  which  led 
to  the  difficulty  of  diagnosis  in  a  case  which  had  occurred  in  the  institution  with 
which  Dr.  Lee  was  connected  as  physician  accoucheur.  The  leading  particulars 
of  the  case  had  been  published,  but  he  (Dr.  Savage)  thought  Dr.  Lee  ought  to 
explain,  for  their  future  guidance,  how  and  why  the  difficulty  had  arisen. 

Dr.  Lee  rose  and  said  it  was  true  that  he  had  never  performed  the  operation 
of  ovariotomy  on  the  living  body,  that  he  had  never  sanctioned  its  performance, 
and  that  he  had  never  seen  it  performed  by  others.  In  the  year  1840,  he  had 
been  invited  by  the  late  Mr.  B.  Phillips  to  be  present  at  the  St.  Marylebone  In- 
firmary to  see  him  operate.  He  (Dr.  Lee)  consented  to  be  present,  but,  being 
professionally  engaged,  did  not  arrive  at  the  infirmary  till  the  operation  had  been 
completed.  The  patient  was  21  years  of  age,  in  good  general  health.  An  inci- 
sion of  two  inches  and  a  half  was  made  through  the  abdominal  parietes ;  the  cyst 
was  seized  with  the  vulsellum ;  330  ounces  of  fluid  evacuated ;  the  opening  en- 
larged ;  the  cyst  drawn  out ;  the  root  tied  and  excised,  and  the  sac  removed 
without  difficulty.  Severe  pain  followed,  with  vomiting.  He  saw  the  patient 
about  half  an  hour  afterwards,  with  rapid,  feeble  pulse,  and  cold  extremities. 
He  was  present  at  the  examination  of  the  body,  when  the  appearances  of  recent 
inflammation  were  observed  within  the  pelvis,  with  a  small  quantity  of  extrava- 
sated  blood.  He  had  seen  the  patient  a  few  days  before  in  excellent  general 
health,  and  if  her  life  had  not  thus  been  suddenly  and  violently  destroyed,  she 
might  have  lived  for  years.  Mr.  B.  Phillips  never  again  performed  the  operation 
of  ovariotomy.  He  (Dr.  Lee)  was  now  told  that  ovariotomy  was  a  simple  ope- 
ration, and  the  reports  published  of  successful  cases  would  lead  to  the  inference 
that  it  was  attended  with  comparatively  little  danger.  No  operation,  he  was 
convinced,  could  be  performed  on  the  human  body  so  dangerous,  except  the 
Csesarean  section.  Indeed,  the  Cesarean  section  and  ovariotomy  resembled  one 
another  in  several  striking  respects.  In  both  an  incision  must  be  made  through 
the  abdominal  parietes,  the  peritoneal  cavity  laid  open,  and  the  bowels  exposed. 
"  I  am  acquainted,"  says  a  statistical  writer  in  the  thirty-fourth  volume  of  the 
Medico-Chirurgical  Transactions,  "with  409  authentic  cases  of  the  Caesarean 
section,  341  of  which  are  collected  in  Kayser's  valuable  essay,  'De  Eventu  Sec- 
tionis  Csesarean.'  In  251  of  these  cases  the  mother  died ;  in  156  she  survived. 
There  can,  however,  be  no  doubt  but  that  these  figures  convey  a  very  exagger- 
ated impression  as  to  the  proportion  of  recoveries,  and  that  the  unfavourable 
estimate  of  English  authors  is  nearer  the  truth.  Both  Kayser  and  Naegele  re- 
gard the  results  given  by  the  published  cases  as  unfair ;  and  the  former  men- 
tions the  fact,  which  of  itself  affords  strong  evidence  on  this  point,  that  while 
the  total  maternal  mortality  amongst  the  cases  which  he  had  collected  was  63 
per  cent.,  the  mortality  of  cases  occurring  in  lying-in  hospitals,  in  which  insti- 
tutions failures  must  of  necessity  be  reported  as  well  as  successes,  amounted  to 
79  per  cent."  The  results  here  stated  were  admitted  to  be  unfair,  he  would  say 
wholly  destitute  of  truth,  and  utterly  unworthy  of  credit.  Did  any  one  person 
there  present  believe  that  of  these  409  cases  the  mortality  was  not  greater  than 
*"  63  per  cent.  ?  It  was  known  that  numerous  fatal  cases  of  Caesarean  section  had 
occurred  on  the  continent,  of  which  no  report  had  ever  been  permitted  to  see 
the  light.    This  applied  forcibly  to  the  statistics  of  ovariotomy,  which  he  had 


1863.] 


Surgery. 


237 


been  told  were  the  sole  foundation  upon  which  all  their  conclusions  respecting 
the  propriety  of  removing  ovarian  cysts  and  tumours  must  rest.  If  all  the  fatal 
cases  of  ovariotomy  had  be.en  published,  there  might  have  been  some  appear- 
ance  of  force  in  this;  at  least,  the  degree  of  danger  would  have  been  indicated. 
But  this  had  not  been  the  course  followed  in  this  country  since  the  operation 
came  to  be  performed.  It  was  notorious  that  numerous  fatal  cases  of  ovariotomy 
had  occurred  of  which  no  report  had  ever  been  published,  and  all  attempts  to 
remove  the  veil  which  concealed  them  had  been  fruitless.  "You  have  related, 
sir.  to  the  Society  (addressing  the  president)  a  successful  case  of  ovariotomy 
performed  many  years  ago  by  Mr.  Walne.  Can  you  inform  the  Society  of  the 
number  of  cases  in  which  he  performed  the  operation  with  disastrous  results, 
of  which  no  account  was  ever  published?"  When  preparing  his  (Dr.  Lee's) 
analysis  of  162  cases  which  had  occurred  in  Great  Britain,  for  this  Society,  he 
wrote  to  Mr.  Walne,  and  requested  him,  on  the  grounds  of  science  and  humanity, 
to  communicate  a  full  report  of  all  his  successful  and  all  his  fatal  cases.  With 
this  request  Mr.  Walne  refused  to  comply  in  the  most  peremptory  manner,  and 
no  accurate  report  had  ever  been  published  of  the  results  of  his  practice.  It 
was  long  since  Mr.  Walne  had  been  heard  of  as  an  ovariotomist ;  but  the  reports 
of  success  in  his  early  career  were  quite  as  flattering  as  those  marvellous  results 
which  had  been  related  to  the  Society  that  evening.  Mr.  Walne  was  not  the 
only  ovariotomist  to  whom  he  (Dr.  Lee)  applied  for  information  on  the  occasion 
without  success.  Another,  whose  fame  as  a  successful  ovariotomist  had  not 
been  surpassed  in  this  country,  made  a  return  to  him  which  was  not  correct,  and 
which  he  was  compelled  to  reject  as  untruthful.  Of  this  ovariotomist  little  had 
been  heard  of  late  years,  and  he  (Dr.  Lee)  believed  he  had  abandoned  the  ope- 
ration altogether.  The  postscript  of  Dr.  Lee's  paper  contained  an  account  of 
all  the  cases  operated  upon  by  Mr.  Lane,  Dr.  Clay,  Mr.  Spencer  Wells,  and 
others,  and  the  history  of  some  fatal  unpublished  cases.  The  Council  of  the 
Society  had  decided  that  these  should  not  be  read.  He  had  requested  the  last 
case  in  his  postscript  to  be  read,  but  that  request  had  not  been  complied  with. 
It  was  a  case  related  in  a  letter  to  Dr.  Noble.  The  operation  was  performed  in 
1855,  with  the  sanction  of  Mr.  Harrison's  colleagues,  and  in  the  presence  of  Dr. 
Noble  and  several  other  medical  men  and  Dr.  Clay.  "I  removed  the  tumour," 
says  Mr.  Harrison,  "  and  the  first  time  I  suspected  it  to  be  uterine  was  on  cut- 
ting through  the  pedicle."  The  patient  had  died  in  eight  hours.  He  (Dr.  Lee) 
was  uncertain  if  this  case  was  published.  Another  letter  in  the  postscript  con- 
tained an  account  of  three  fatal  cases.  One  of  these  had  been  published  as  a 
fortunate  case.  The  histories  of  many  others  had  been  communicated  to  him, 
not  referred  to  in  the  postscript.  He  had  himself  seen  a  considerable  number 
of  cases  where  the  operation  was  performed,  contrary  to  his  advice,  with  rapidly 
fatal  results,  of  which  no  reports  had  been  published  by  which  the  cases  could 
be  recognized.  He  passed  the  house  of  one  of  those  patients  that  afternoon. 
There  was  hope  in  this  case  that,  with  ordinary  treatment,  this  patient  might 
have  lived  for  years.  The  operation  was  very  lately  performed,  with  rapidly  fatal 
results,  upon  a  lady  he  had  seen  in  the  country  on  the  sea-coast.  By  no  efforts 
had  he  succeeded  in  bringing  to  light  the  details  of  that  case.  If  the  operation 
was  so  simple  and  so  successful,  why  were  these  cases  concealed  from  the  public 
and  the  profession.  He  (Dr.  Lee)  saw  a  case  near  Brixton  some  time  ago,  since 
the  publication  of  his  "  Analysis."  There  was  a  great  mass  of  ovarian  cysts 
and  tumours  firmly  adhering.  He  never  saw  a  more  unfavourable  case  for  an 
operation ;  but  a  most  marvellously  successful  ovariotomist  was  called  to  see 
the  patient,  and  he  pronounced  it  a  favourable  case.  He  said  that  he  (Dr.  Lee) 
was  wholly  ignorant  of  the  subject.  This  ovariotomist  made  an  incision  from 
stem  to  stern,  not  an  exploratory  incision,  but  nothing  could  be  removed  after 
repeated  attempts,  and  the  patient,  was  soon  in  her  grave.  Dr.  Lee  wrote  to 
the  ordinary  medical  attendant  some  weeks  after,  inquiring  what  had  become  of 
her.  He  received  no  reply  of  any  kind.  He  wrote  a  second  time,  without  suc- 
cess. Many  months  after,  Dr.  Lee  accidentally  met  a  clergyman  at  Clapham, 
who  informed  him  that  the  operation  had  been  performed  with  speedily  fatal 
results,  and  that  he  had  buried  her.  It  would  be  useless  to  multiply  such  cases; 
and  yet  he  was  told  that  the  statistics  of  ovariotomy  were  to  form  the  ground- 


Progress  of  the  Medical  Sciences.  [Jan. 


work  of  all  decisions  respecting  ovariotomy,  and  that  they  were  worthy  of  trust. 
An  attempt  had  been  made  to  institute  a  comparison  between  the  results  of 
ovariotomy  and  great  surgical  operations.  A  chronic  ovarian  disease,  after  last- 
ing four  years,  and  not  threatening  life,  bore  no  resemblance  to  a  case  of  stran- 
gulated hernia,  an  aneurism  ready  to  burst,  or  a  shattered  limb  with  hemorrhage 
from  the  large  arteries.  Ovariotomy  could  not  be  compared  to  any  of  the  great 
operations  of  surgery.  In  the  cases  of  ovariotomy  called  unsuccessful,  the 
patients  had  been  suddenly  deprived  of  life  by  violence  without  any  necessity. 
But  it  was  not  from  some  occasional  cases  of  recovery  from  the  operation,  such 
as  those  related  that  evening,  that  a  correct  opinion  of  ovariotomy  could  be 
formed.  All  the  facts  must  be  taken  into  account,  otherwise  no  sound  judgment 
could  be  formed  of  the  difficulty  of  the  diagnosis,  and  the  danger  of  the  opera- 
tion. It  appeared,  from  the  analysis  of  162  cases,  that  a  successful  instance 
occurred  in  America,  and  was  published  in  the  Edinburgh  Medical  and  Sur- 
gical Journal  in  1822.  He  had  thought  that  this  was  the  first  case;  but  it  was 
now  stated  that  the  operation  had  been  performed  by  Dr.  M'Dougal  before. 
This  was  a  matter  of  no  importance.  It  could  not  be  denied  that  the  publica- 
tion of  a  successful  case  took  place  in  1822 ;  and  he  had  supposed  Mr.  Lizars, 
in  consequence  of  this  case,  had  recourse  4o  operation.  In  Mr.  Lizars's  first 
case,  there  was  no  ovarian  disease  to  be  removed.  In  the  second,  the  disease 
was  removed,  but  the  other  ovary  was  diseased  and  could  not  be  removed.  This 
patient  was  afterwards  seen  by  some  surgeons  in  London.  He  believed  Mr. 
Lawrence  saw  her,  with  a  great  cicatrix  of  the  abdomen,  and  a  large  mass  of 
disease  within.  The  third  patient  operated  upon  by  Mr.  Lizars  died.  In  the 
fourth  case,  there  was  no  ovarian  disease  to  be  removed.  About  1829,  a  case 
similar  to  this  was  seen  in  Guy's  Hospital  by  Dr.  Gooch.  In  1826,  Dr.  Gran- 
ville made  an  incision  of  nine  inches  long  through  the  abdominal  parietes,  and  a 
large  ovarian  tumour  was  brought  into  view,  which  had  such  extensive  adhesions 
that  it  could  not  be  removed.  In  1829,  Dr.  Granville  operated  again,  and  re- 
moved a  tumour  weighing  nine  pounds,  which  was  supposed  to  be  ovarian,  but 
it  was  a  large  fibrous  tumour  of  the  uterus.  Dr.  Lee  examined  this  tumour  in 
the  recent  state,  and  ascertained  that  it  had  adhered  to  the  fundus  uteri  by  a 
thick  peduncle,  around  which  a  ligature  had  been  applied,  and  the  root  cut 
across.  A  portion  of  small  intestine  which  had  come  in  contact  with  the  in- 
cised root  became  inflamed  and  gangrenous,  and  the  patient  soon  perished  mis- 
erably. The  preparation  of  the  parts  was  long  in  the  possession  of  Mr.  North. 
Dr.  Granville  was  about  to  operate  upon  another  patient,  but  Mr.  0.  Clarke  re- 
commended the  patient  not  to  submit  to  the  operation,  and  she  lived  some  years 
after,  and  died  a  natural  death  at  Barnes.  Dr.  Scott  examined  the  body,  and 
presented  the  tumour  to  Dr.  Lee,  which  was  the  uterus,  with  a  fibrous  tumour 
imbedded  in  its  walls  of  the  size  of  three  human  heads ;  it  was  in  Dr.  Lee's 
collection  at  St.  George's  Hospital.  Dr.  Granville  had  far  greater  experience 
in  the  practice  of  midwifery  than  any  who  had  that  evening  spoken.  In  1835, 
Mr.  Jeaffreson  performed  the  operation,  and  the  patient  recovered.  From  that 
time  to  the  present,  the  operation  had  occasionally  been  performed  with  success, 
but  as  often,  he  (Dr.  Lee)  believed,  with  fatal  results,  if  the  whole  truth  were 
revealed.  About  the  same  time,  Mr.  King  attempted  to  perform  the  operation, 
but  the  ovarian  disease  could  not  be  removed,  and  the  patient  died.  In  1834 
he  repeated  the  operation  with  success,  and  again  in  1836.  Then  followed  three 
successful  cases  and  one  fatal.  Then  followed  six  fatal  cases  running,  in  which 
the  operation  was  performed  by  Messrs.  Hargraves,  B.  Phillips,  Aston  Key,  B. 
Cooper,  and  Mr.  Greenhow.  In  looking  over  one  column  of  his  "Analysis,"  he 
(Dr.  Lee)  could  see  "Died — died — died — died — died — died"  in  a  few  days — he 
might  say  killed.  All  these  operations  were  performed  by  distinguished  sur- 
geons, and  none  of  them  repeated  the  operation.  In  fact,  the  operation  required 
undoubtedly  great  hardihood.  So  far,  it  was  an  operation  such  as  had  been  de- 
scribed. He  would  refer  those  who  wished  to  know  all  the  facts  to  the  remainder 
of  the  "  Analysis,"  by  which  it  appeared  that,  of  162  authentic  cases  in  which 
the  operation  had  been  undertaken,  in  60  the  ovarian  disease  could  not  be  re- 
moved, 19  of  which  proved  fatal ;  of  the  remaining  102  cases  in  which  the  ope- 
ration was  completed,  42  terminated  fatally.    From  these  facts,  he  concluded 


1863.] 


Surgery. 


239 


that  ovariotomy  and  the  Cesarean  section  were  the  two  most  dangerous  opera- 
tions which  could  be  performed  on  the  human  body.  The  postscript  of  his  (Dr. 
Lee's)  paper,  which  the  council  had  refused  to  read,  contained  reports  of  all  the 
cases,  successful  and  fatal,  which  had  come  under  the  eare  of  Mr.  Spencer  Wells, 
and  he  believed  that  that  gentleman  had  concealed  no  fatal  case.  One  of  the 
successful  cases,  he  (Dr.  Lee)  had  seen  in  Burton  ward,  St.  George's  Hospital, 
and  he  thought  the  case  as  favourable  for  the  operation  as  any  he  had  ever  seen. 
He  summoned  a  consultation  of  the  surgeons ;  but  they  declined  to  operate  un- 
less he  sanctioned  the  operation,  which  he  could  not  do,  knowing  that,  until  the 
abdomen  was  laid  open,  it  was  impossible  to  tell  whether  the  cyst  could  be  re- 
moved or  not,  and  knowing  also  that  the  patient's  lite  would,  under  the  most 
favourable  circumstances,  be  exposed  to  the  utmost  danger.  She  went  to  the 
Samaritan  Hospital,  and  was  operated  upon  by  Mr.  Spencer  Wells  with  suc- 
cess; but  she  had  a  narrow  escape  with  her  life,  and  she  told  him  (Dr.  Lee)  that 
she  considered  herself  on  the  brink  of  the  grave  during  several  days.  But  the 
perusal  of  the  successful  cases  of  Mr.  Spencer  Wells  had  no  doubt  led  to  most 
fatal  results.  In  reading  some  of  these  cases,  a  lady  in  Ireland,  who  had  ovarian 
disease,  resolved  to  have  it  extirpated,  being  convinced  that  ovariotomy  was  not 
attended  with  much  danger.  A  pecuniary  negotiation  took  place  between  her 
and  Mr.  Wells,  but  it  came  to  nothing ;  and  another  ovariotomist  went  to  Ire- 
land, and  performed  the  operation.  He  (Dr.  Lee)  had  been  informed  that  he 
represented  the  case  as  not  unfavourable,  and  that  his  fee  was  to  be  300  guineas, 
and  100  guineas  every  day  he  remained  with  the  patient  after  the  operation. 
Bargains  of  this  description,  he  (Dr.  Lee)  had  been  informed,  were  not  uncom- 
mon. The  operation  was  easily  performed,  and  the  operator  ran  round  the  table, 
kicking  up  his  heels  in  triumph;  but  these  feelings  of  delight  were  of  short  dura- 
tion, for  the  patient  soon  began  to  sink,  and  died  in  eighteen  hours.  Had  Mr. 
Spencer  Wells  ever  read  any  report  of  this  case  ?  It  was  impossible  to  deny 
that  the  question  now  under  discussion  was  a  money  question,  and  not  one  of 
science  and  humanity.  Mr.  Spencer  Wells  had  reduced  all  his  cases  under  three 
heads.  One  of  these  comprehended  all  the  cases  in  which  what  had  been  called 
exploratory  incisions  had  been  made,  and  these  were  spoken  of  as  if  they  were 
things  of  no  very  serious  importance,  though  they  had  sometimes  caused  death. 
"You  would  not,  I  am  convinced,"  concluded  Dr.  Lee,  "  view  them  in  this  light 
if  incisions  were  made  through  your  abdominal  parietes,  and  the  fingers  of  an 
ovariotomist  introduced  amongst  your  bowels  to  hunt  for  adhesions.  Mr.  Listen 
had  a  great  horror  of  such  exploratory  incisions  and  of  all  ovariotomists.  He 
called  them  '  belly  rippers,'  with  a  B  before  and  a  B  after.  The  meaning  of 
these  two  B's  I  must  not  state  plainly  to  the  Society." — Med.  Times  and  Gaz., 
Nov.  22,  1862. 

57.  Ovariotomy  in  Ireland. — Dr.  Kidd  exhibited  to  the  Dublin  Pathological 
Society  (April  12,  1862)  an  ovarian  cyst  which  he  had  removed  and  gave  a  his- 
tory of  the  case,  which  terminated  fatally.  He  stated  that  this  was  only  the 
third  time  the  operation  had  ever  been  performed  in  Ireland.  The  first  was  in 
a  case  of  his  in  which  Dr.  Clay  of  Manchester,  had  operated,  in  which  there 
were  no  adhesions,  and  the  patient  died  within  23  hours.  The  second  was  Dr. 
Gordon's  case,  in  which  there  were  adhesions  to  a  slight  extent,  and  which  was 
also  fatal. — Dublin  Quarterly  Joum.  Med.  Sci.,  Nov.  1862. 

58.  Ovarian  Dropsy  cured  by  Iodine  Injections. — The  following  communica- 
tion from  Dr.  Bullen,  of  Cork,  was  read  to  the  Edinburgh  Obstetrical  Society: — 

"  Last  year,  in  a  case  of  ovarian  dropsy,  after  drawing  off  several  gallons  of 
glairy  fluid,  I  threw  two  drachms  of  compound  tincture  of  iodine  in  an  ounce  of 
water  into  the  ovarian  sac.  The  woman  complained  of  great  heat  in  the  part, 
but  the  symptoms  were  not  severe.  She  left  the  Mercy  Hospital  much  relieved, 
with  a  hard  tumour  in  the  iliac  fossa.  At  the  end  of  six  months  this  woman 
died  of  phthisis,  and  on  dissection  the  ovary  was  found  converted  into  a  solid 
tubercular  tumour  about  the  size  of  a  goose's  egg.  There  was  not  more  than 
half  an  ounce  of  muco-purulent  fluid  in  the  sac." 

Dr.  A.  Simpson  stated  that  he  had,  a  few  days  ago,  assisted  his  uncle  in  tap- 


240 


Progress  of  the  Medical  Sciences. 


[Jan. 


ping:  a  woman  for  ovarian  dropsy,  and,  before  injecting  iodine,  he  washed  the  sac 
out  twice  with  about  twelve  ounces  of  tepid  water,  for  the  purpose  of  removing 
the  albuminous  fluid  which  remained  adherent  to  the  walls  and  would  have  pre- 
vented the  iodine  from  acting  so  actively  as  it  would  otherwise  do. 

Dr.  Andrew  Inglis  alluded  to  a  woman  at  present  in  the  Koyal  Infirmary 
affected  with  peritonitis,  whom  Dr.  Simpson  had  tapped  and  injected  some  years 
ago  for  ovarian  dropsy,  and  in  whom  the  disease  never  recurred.  The  only  ves- 
tige remaining  was  a  small,  hard  tumour,  the  size  of  an  orange,  on  the  lower  part 
of  the  abdomen  on  the  left  side. — Edinburgh  Med.  Journal,  Oct.  1862. 


OPHTHALMOLOGY. 

59.  Inferior  Section  of  Cornea  for  Extraction  of  Cataract. — Mr.  Ernest 
Hart  considers  the  inferior  section  of  the  cornea  preferable  to  the  superior,  in  the 
operation  of  extraction  of  cataract.  My  own  experience,  he  says  (Lancet,  Oct. 
18,  1862),  and  the  observation  of  a  long  series  of  cases  in  the  practice  of  my 
friend,  Mr.  White  Cooper,  prompt  me  to  speak  much  more  favourably  of  the 
inferior  section  than  do  some  of  our  classical  writers  on  ophthalmic  surgery. 
From  the  results  of  a  large  number  of  cases  of  extraction,  in  rather  more  than 
half  of  which  I  have  operated  by  the  inferior  section,  I  have  great  reason  to  be 
satisfied  with  that  method.  In  a  number  of  other  cases  which  I  have  had  oppor- 
tunities of  observing,  the  result  has  been  as  good. 

It  has  been  objected  to  the  inferior  section  that  the  edge  of  the  lower  lid  is 
likely  to  become  engaged  in  the  wound,  and  so  to  retard  union ;  and  that  by  its 
position,  being  bathed  in  the  tears  of  the  inferior  cul-de-sac  of  the  mucous  mem- 
brane, the  healing  of  the  cicatrix  must  suffer  from  that  contact.  I  believe  both 
these  objections  to  be  partly  fanciful,  and  that  they  are  not  fully  borne  out  in 
practice.  I  have  never  seen  more  rapid  union  than  in  the  cases  of  inferior  sec- 
tion, and  the  excellence  of  the  ultimate  result  is  greatly  aided  by  the  more 
favourable  conditions  which  it  offers  for  executing  the  operation  to  perfection. 
In  employing  the  superior  section,  there  are  difficulties  inherent  to  that  method. 
These  occur  especially  in  the  second  and  third  stages  of  the  operation.  After 
the  section  has  been  made  and  the  eye  released,  the  ball  turns  upward  under  the 
lid  so  as  to  bury  the  incision,  and  the  introduction  of  the  cystitome,  the  expul- 
sion of  the  lens,  and  the  perfect  clearing  of  the  pupil  are  all  infinitely  more 
difficult  than  in  the  lower  section.  Practice  teaches  how  to  overcome  these 
difficulties ;  but  I  am  persuaded  that  the  greater  facility  with  which  the  pupil 
may  be  cleared  and  the  parts  adjusted  has  the  effect  of  producing  more  per- 
fect results  from  that  operation.  The  accidents  of  operation — and  in  these  I 
include  wounding  the  iris,  effusion  of  blood  into  the  anterior  chamber,  difficulty 
in  extracting  the  crystalline  lens,  incomplete  incision  of  the  capsule,  declension 
of  the  lens  into  the  vitreous  humour — may  be  almost  wholly  excluded  from 
operation  by  the  inferior  section.  By  my  own  experience  I  am  led  to  similar 
conclusions  in  respect  to  prolapse  of  the  iris  and  synechia — two  of  the  most 
troublesome  accidents  so  far  as  the  after-consequences  are  concerned.  In  one 
or  two  patients  I  have  operated  with  the  same  degree  of  care  by  the  inferior 
section  on  the  one  eye  and  by  the  superior  section  on  the  other,  and  the  result 
has  confirmed  a  preference  for  the  former  method.  Thus,  in  Catharine  B.,  who 
was  lately  under  operation  at  the  West  London  Hospital,  the  result  on  the  left 
eye  (inferior  keratotomy)  was  perfect ;  in  the  right  (superior  keratotomy)  the 
iris  is  adherent  to  the  corneal  cicatrix.  The  same  has  happened  in  two  other  of 
my  crises  lately.  I  know  no  more  beautiful,  simple,  and  successful  operation 
than  extraction  by  the  lower  flap. 

GO.  Some  Affections  of  Vision  Apparently  of  Syphilitic  Origin. — Dr.  K. 
Hibbert  Taylor,  Senior  Surgeon  to  the  Liverpool  Eye  and  Ear  Infirmary, 
has  published  (British  Med.  Jour.,  March  29,  1862)  some  interesting  observa- 
tions on  these  affections. 


1863.] 


Ophthalmology. 


241 


"  Any  one  who  has  seen  much  of  diseases  of  the  eye,"  he  remarks,  "  especially 
as  they  present  themselves  in  public  institutions  for  that  class  of  maladies,  must 
have  had  his  attention  drawn  occasionally  to  cases  apparently  of  syphilitic  origin, 
in  which  the  failure  of  vision  could  not  be  accounted  for  by  any  appreciable 
change  in  the  external  structures  of  the  eyeball.  There  is  probably  no  redness 
of  the  superficial  tissue  present,  nor  any  trace  of  iritis,  as  usually  manifested  by 
thickening  and  loss  of  brilliancy  of  the  iris,  and  adhesion  of  its  pupillary  border 
to  the  capsule  of  the  lens. 

"  On  inquiring  into  the  history  of  these  cases  it  will  be  found  that  syphilitic 
affections,  both  primary  and  secondary,  have  been  observed,  and  generally  at 
periods  rather  remote  from  the  occurrence  of  the  symptoms  now  complained  of. 
Among  the  secondary  symptoms  previously  noted  iritis  may  or  may  not  have 
occurred  ;*  and  if  it  has  been  present,  generally  all  traces  of  its  existence  have 
disappeared. 

"  My  attention  was  first  awakened  with  regard  to  such  cases  many  years  ago, 
and  I  confess  that  for  a  long  period  they  seemed  very  puzzling.  We,  and  I 
speak  of  those  of  my  own  standing  in  age,  have  been  so  accustomed,  from  the 
influence  of  early  professional  tuition,  and  the  habits  of  observation  founded 
upon  it,  to  regard  syphilitic  affections  of  the  eye  as  limited  almost  exclusively 
to  one  disease,  iritis,  that  it  was  with  difficulty  one  could  shake  off  this  inherited 
belief,  and  rise  to  the  wider,  and,  I  believe,  juster  view  of  the  subject  which 
these  cases  suggest.  For  myself,  I  must  admit  that  it  was  only  step  by  step 
that  I  was  irresistibly  led  to  the  conclusion  that  the  influence  of  the  syphilitic 
poison  upon  the  tissues  of  the  eye  possessed  a  more  extended  range  than  had 
hitherto  been  assigned  to  it,  and  that  the  deeper  tissues  of  the  choroid,  retina, 
and  vitreous  humor,  were  probably  liable  to  have  their  structures  deranged  and 
their  functions  impaired  in  like  manner  with  those  more  open  to  inspection. 

"  The  use  of  the  ophthalmoscope,  which  has  already  rendered  such  invaluable 
service  in  investigating  the  pathology  of  the  deep  structures  of  the  eyeball,  has 
clearly  shown  that  these  surmises  were  well  founded,  and  that  the  failure  of 
vision  in  these  instances  was  amply  accounted  for  by  the  structural  changes 
which  we  have  thus  been  enabled  to  detect. 

"  In  a  recent  number  of  the  Medical  Times  and  Gazette  seven  cases  are  nar- 
rated, occurring  in  the  practice  of  the  Royal  London  Ophthalmic  Hospital, 
which  illustrate  this  subject  on  various  points,  and  are  worthy  of  the  attention 
of  those  who  feel  an  interest  in  it.  In  one  case  there  was  dimness  of  vision  of 
one  eye,  following  .primary  and  secondary  syphilitic  symptoms  which  had  oc- 
curred some  months  previously,  but  had  then  nearly  disappeared,  and  there  was 
no  iritis.  Examination  with  the  ophthalmoscope  revealed  a  congested  and  hazy 
condition  of  the  retina,  with  the  appearance  of  a  thin  gauze  before  it.  The 
patient"  was  treated  with  mercurials  till  the  mouth  was  slightly  affected,  and 
afterwards  a  milder  action  was  kept  up  with  some  intermissions  during  several 
months.  At  the  expiration  of  this  period  the  sight  was  nearly  perfectly  restored 
in  the  affected  eye,  and  the  morbid  ophthalmoscopic  appearances  had  vanished. 
In  another  instance  the  symptoms  in  the  eye  first  showed  themselves  six  months 
after  the  primary  infection  ;  and  at  the  period  of  admission  to  the  hospital  a  well- 
marked  syphilitic  rash  existed  upon  the  shoulders.  Both  eyes  were  equally 
affected  in  this  case,  and  the  symptoms  complained  of  were  dim  muscse,  and  the 
appearance  of  clouds  of  smoke.  The  patient  was  unable  to  read  the  largest 
type,  or  tell  the  hour  by  the  clock.  The  attack  commenced  rather  suddenly, 
first  in  one  eye,  and  shortly  afterwards  in  the  other.  The  ophthalmoscope 
showed  a  turbid  vitreous  humour  in  each  eye,  with  numerous  white  silvery  films 
floating  in  its  structure.  The  patient,  a  married  woman,  was  nursing  an  infant ; 
but,  except  being  somewhat  reduced  by  lactation,  was  in  fair  health.  Mercury 
was  prescribed,  and  the  baby  to  be  weaned ;  but  unfortunately  no  record  of 
the  result  is  given. 

"  In  another  case,  the  minute  details  of  which  I  need  not  repeat,  the  affection  of 
the  eyes  followed  the  primary  syphilitic  disease  after  an  interval  of  several  years, 
and  examination  with  the  ophthalmoscope  disclosed  extensive  structural  changes 
in  the  choroid,  optic  disk,  and  retinal  vessel,  so  great  as  to  preclude  any  hope 
of  the  restoration  of  sight. 

No.  LXXXIX.— Jan.  1863.  16 


242 


Progress  of  the  Medical  Sciences.  [Jan. 


"  I  need  not  further  multiply  examples  from  this  source,  as  they  all  tend,  more 
or  less,  to  show  the  occurrence  of  serious  structural  changes  in  the  deep  tissues 
of  the  eye,  materially  affecting  vision,  and  taking  place  at  periods  more  or  less 
remote  from  the  infection  of  primary  syphilis.  The  point  of  most  interest,  re- 
garding such  cases,  is  this,  that,  in  general,  they  do  not  present  any  obvious 
external  appearance  of  their  syphilitic  origin,  and  unless  the  history  of  each  has 
been  minutely  inquired  into,  its  real  nature  would  be  misunderstood,  and  the 
treatment  most  likely  to  be  effectual  would  not  be  adopted.  Nor  without  the 
aid  of  the  ophthalmoscope  could  we  detect  those  changes  in  the  deep  tissues 
which  give  no  outward  visible  sign  of  their  existence,  and  which  yet  are  some- 
times so  extensive  and  important  as  to  be  wholly  irreparable. 

"  The  following  case,  which  I  recently  met  with  in  private,  illustrates  several 
of  the  points  which  appear  to  be  characteristic  of  this  form  of  secondary  dis- 
ease, and  affords,  in  addition,  a  good  example  of  the  value  of  the  ophthalmoscope, 
as  without  its  aid  it  would  have  been  impossible  to  refer  the  failure  of  vision  to 
its  true  cause,  in  partial  disorganization  of  the  deep  tissues  of  the  eyeball. 

"  Mr.  W.,  a  tall,  stout,  soldier-looking  man,  connected  with  the  land-transport 
corps  in  India,  and  twenty-two  years  resident  in  that  country,  consulted  me 
about  a  month  ago,  complaining  of  weakness  and  wateriness  of  both  eyes',  with 
defective  vision,  especially  in  the  right.  He  stated  that  about  five  years  ago, 
while  in  a  hot  district  of  India,  he  first  observed  an  appearance  of  a  glare,  like 
stars,  before  the  right  eye ;  and  objects  looked  at  seemed  to  be  more  distant 
than  they  really  were.  Yision  with  this  eye  was  also  indistinct ;  but  he  was 
able  to  distinguish  one  person  from  another  by  their  features,  and  with  some 
pain  and  difficulty  could  make  out  the  letters  of  a  large  type.  Since  then,  vision 
has  still  further  declined,  and  the  eye  has  become  weak  and  watery.  During  the 
last  eighteen  months,  the  left  eye  has  also  become  weak  and  watery ;  but  the 
sight  is  very  little  affected  as  yet.  Eather  more  than  five  years  ago,  or  about 
two  months  previously  to  the  affection  of  his  sight,  he  had  primary  venereal 
sores,  followed,  in  about  a  fortnight,  by  an  eruption  over  the  arms  and  chest, 
which,  however,  disappeared  in  a  few  days,  and  was  succeeded  by  scaliness  of 
the  palms  of  the  hands  and  soles  of  the  feet,  attended  with  heat  and  dryness, 
which  continued,  more  or  less,  till  nine  months  ago.  He  had  also  pains  of  the 
bones,  coming  on  six  months  after  the  primary  disease,  and  lasting  about  a 
month.  He  says  that  he  never  took  mercury  so  as  to  affect  the  mouth,  but  treated 
himself  with  one-eighth  of  a  grain  of  the  bichloride  once  daily  during  several 
months.  He  also  applied  black  wash  to  the  chancre,  which  healed  in  about  a 
week.  He  has  never  had  inflammation  of  the  external  tissues  of  the  eyeballs, 
and  there  are  no  traces  of  iritis  visible.  He  states  that  he  has  used  his  eyes 
much  in  writing,  sometimes  till  late  in  the  night.  There  was  slight  conjuncti- 
vitis observable  in  the  right  eye  when  I  first  saw  him,  and  the  pupil  in  each  eye 
was  of  medium  size,  tolerably  regular,  and  sluggish  in  its  movements. 

"  Examined  with  the  ophthalmoscope,  the  optic  disk  in  the  right  eye  was 
indistinctly  seen,  as  if  through  a  veil  or  gauze,  and  was  perhaps  smaller  in  di- 
mensions than  usual.  On  the  patient  rolling  the  globe  directly  upwards,  the 
lower  part  of  the  retina  was  seen  to  be  thickly  studded  with  black  spots,  varying 
in  size  and  figure,  imparting  to  the  membrane  the  appearance  of  a  leopard's 
skin.  These  appearances  alone,  independently  of  the  history  of  the  case,  would 
have  sufficed  to  indicate  the  syphilitic  origin  of  the  disease,  inasmuch  as  they 
seem  to  be,  in  a  great  measure,  pathognomonic  of  such  affections  of  the  eye. 

"  With  regard  to  treatment,  mercury  is  certainly  to  be  relied  upon  as  the 
mo.st  effective  remedy,  especially  when  the  structural  changes  in  the  deep  tissues 
are  extensive  and  material,  as  in  the  instance  last  cited ;  and  the  greatest  amount 
of  good  which  it  is  capable  of  doing  will  probably  be  obtained  by  exhibiting  it 
in  small  and  frequently  repeated  doses,  affecting  the  gums  slightly,  and  main- 
taining the  action  during  several  weeks.  In  milder  cases,  where  the  ophthalmo- 
scopic appearances  do  not  show  more  than  a  gauzy  haziness  of  the  retina,  and 
indistinctness  of  the  optic  disk,  the  iodide  of  potassium  has  been  given  with 
good  results.  In  the  case  from  India,  above  mentioned,  I  prescribed  calomel 
and  opium  in  small  doses ;  but.  as  the  patient  lives  at  a  distance,  and  has  not 
yet  reported  his  condition,  I  cannot  speak  as  to  the  result. 


1863.] 


Ophthalmology. 


243 


"  In  addition  to  the  above  remarks,  I  may  add  that,  during  a  recent  visit  to 
London,  I  had  an  opportunity  of  conversing  on  this  subject  with  several  of  the 
surgeons  connected  with  the  ophthalmic  institutions  in  the  city,  as  well  as  with 
others  of  much  experience  in  diseases  of  the  eye,  and  I  found  that  their  obser- 
vations in  this  class  of  diseases  tallied  very  nearly  with  my  own.  In  the  wide 
field  which  the  metropolitan  ophthalmic  institutions  present  these  diseases  are 
of  frequent  occurrence,  and  often  appear  in  very  aggravated  forms ;  but  even 
in  our  more  limited  provincial  spheres,  I  am  inclined  to  think  that  they  are 
oftener  to  be  met  with  than  we  perhaps  suppose,  and  that  they  have  only  hitherto 
escaped  our  notice,  either  from  our  attention  not  having  been  directed  to  the 
subject,  or  because,  although  we  may  have  observed  the  consequences  of  the 
disease  in  the  production  of  defective  vision,  it  has  not  been  referred  to  its  true 
cause,  the  influence  of  the  syphilitic  poison." 

61.  Ophthalmic  Ointments. — Mr.  W.  White  Cooper  states  (Lancet,  June 
28,  1862)  that  for  some  time  past  his  attention  has  been  directed  to  obtaining 
a  basis  for  ophthalmic  ointments  which  shall  neither  become  rancid  nor  irritat- 
ing to.  the  eye.  The  material  which  possesses  these  qualifications  in  the  highest 
degree  appears  to  be  the  butter  obtained  from  the  Theobroma  cocoa  nut,  from 
which  chocolate  is  made.  This  nut  contains  about  four-tenths  of  its  weight  of 
a  fixed  oil  of  the  consistence  of  firm  tallow ;  having  a  rather  agreeable  and 
characteristic  smell,  and  little,  if  any,  tendency  to  become  rancid.  The  butter 
is  obtained  by  roasting  the  nuts,  bruising  them,  and  then  submitting  them  to 
strong  pressure  between  heated  metallic  plates.  Though  very  firm,  it  has  the 
property  of  becoming  fluid  at  a  low  temperature,  and  when  applied  to  the  skin 
feels  cool  and  pleasant.  I  have  reason  to  believe  that  the  concrete  oil  of  the 
cocoa  nut  ( Cocos  nucifera)  is  sometimes  mistaken  for  the  butter  of  the-  Theo- 
broma, but  it  is  deficient  in  the  characteristic  properties  mentioned,  being  soft, 
often  rancid,  and  used  chiefly  for  making  candles  and  soap. 

I  have  had  the  cacao  butter  mixed  with  the  nitric-oxide  of  mercury,  then 
moulded  into  pencils,  whereby  it  can  be  applied  to  the  edge  of  the  eyelid,  or 
any  other  point,  with  great  facility.  The  firmness  of  the  butter  renders  it  an 
admirable  material  for  suppositories,  and  its  cooling  character  adds  to  its  value 
as  an  application  to  haemorrhoids,  &c.  Should  objection  be  made  to  its  firm- 
ness as  an  ophthalmic  preparation,  it  can  be  mixed  with  olive  oil,  the  best  pro- 
portion being  two  parts  of  the  cacao  butter  to  three  of  oil ;  I  mention  this,  as 
patients  occasionally  find  fault  with  the  stiffness  of  the  pure  butter. 

Benzoated  lard  ranks  next  to  cacao  butter,  and  the  fat  obtained  from  the 
omentum  of  the  calf  is  a  sweet  and  pure  material,  though  it  does  not  keep  so 
long  as  .either  of  the^other  preparations. 

62.  Opium  in  Conjunctivitis. — Mr.  W.  "White  Cooper  remarks  (Lancet, 
June  28)  that  "  a  weak  solution  of  the  extract  of  opium — one  grain  to  the  ounce 
— has  a  most  beneficial  influence  on  many  cases  of  conjunctivitis.  I  have  seen 
instances  in  which  the  inflammation  yielded  to  this,  having  resisted  every  other 
application.  The  wine  of  opium  dropped  into  the  eye  is  a  well-known  remedy, 
but  very  painful,  the  pain  being  caused  by  the  spirit.  Mr.  Squire  informs  me 
that  the  new  Pharmacopoeia  will  contain  a  fluid  extract  of  opium,  in  which  the 
proportion  of  spirit  is  only  two  ounces  to  the  pint.  This  will  probably  super- 
sede the  vinum  opii,  as  I  believe  the  benefit  is  mainly  due  to  the  opium,  and 
that  the  aromatics  and  the  strong  wine  can  be  alike  dispensed  with. 

Cases  are  occasionally  met  with  in  which  opium  excites  rather  than  allays 
irritation.  I  prescribed  a  collyrium  of  six  grains  of  extract  of  opium  in  six 
ounces  of  rose-water  for  a  lady  who  was  suffering  from  slight  conjunctivitis.  It 
greatly  aggravated  the  inflammation,  and  the  patient  stated  that,  with  her, 
opium  invariably  acted  as  a  powerful  irritant. 

A  popular  collyrium  is  a  combination  of  diluted  Goulard  water  with  vinum 
opii;  this  is  open  to  the  grave  objection  that  an  insoluble  meconate  of  lead  is 
formed,  which  may  become  impacted  in  the  cornea,  leaving  an  indelible  mark  if 
there  be  abrasion  or  ulceration  present.  Of  this  I  have  seen  many  examples. 
The  left  eye  of  an  artist  of  my  acquaintance  has  been  rendered  useless  from 


244 


Progress  of  the  Medical  Sciences. 


[Jan. 


childhood  by  a  patch  of  such  deposit  in  the  centre  of  the  cornea.  As  a  rule,  it 
is  safest  not  to  employ  lead,  or  other  turbid  lotions,  in  strumous  or  exanthe- 
matous  affections  of  the  eye,  these  being  frequently  attended  with  ulceration  of 
the  cornea.  Lotions  of  zinc  and  alum,  and  the  solutions  of  vegetable  extracts, 
as  opium,  poppy,  or  belladonna,  should  be  filtered,  and  if  the  latter  are  intended 
to  be  kept,  even  for  a  few  days,  a  little  glycerine  should  be  added  to  prevent 
the  formation  of  acetic  acid  by  the  change  the  vegetable  matter  undergoes, 
which  also  gives  rise  to  mouldiness. 


MIDWIFERY. 

63.  Painless  Parturition. — Dr.  George  Smith,  of  Madras,  communicated  to 
the  Obstetrical  Society  of  Edinburgh  the  following  example  of  this  : — 

"  Some  years  ago  I  was  engaged  to  attend  an  English  lady  during  her  ap- 
proaching confinement,  and  was  startled  one  day  by  a  hasty  summons,  coupled 
with  the  information  that  the  child  had  been  suddenly  born  without  warning  of 
any  kind.  On  reaching  my  patient's  residence,  I  found  that  the  child  had  been 
born  about  ten  minutes,  and  that  it  was  still  lying,  with  the  umbilical  cord  uncut, 
close  to  the  mother's  body.  The  native  female  servant,  at  the  lady's  order,  had 
left  the  child  untouched,  merely  raising  the  bedclothes  a  little  to  permit  the  free 
access  of  air  for  the  purpose  of  respiration. 

"  On  inquiry,  the  lady  informed  me  that  she  had  been  for  some  time  expecting 
her  confinement  daily;  that  the  previous  night  she  had  felt  as  usual;  but  that 
she  had  had  occasion  to  rise  frequently  to  attend  upon  her  sickjjhild,  and  that 
she  had  got  up  as  usual  about  half-past  five  A.  M.,  feeling  well,  and  having  no 
indication  of  the  near  approach  of  labour.  Further,  that  during  the  forenoon 
she  had  walked  down  a  long  flight  of  steps,  and  across  a  gravelled  walk  to  a 
smaller  house  within  the  enclosure  of  her  own  grounds,  where,  feeling  a  little 
tired,  she  had  lain  down  upon  a  bed — that  soon  after  she  experienced  slight  dis- 
comfort, likened  by  her  to  ill-defined  uneasiness  of  the  abdomen  under  the 
operation  of  a  mild  laxative,  followed  by  an  impression  that  some  solid  warm 
body  was  lying  in  contact  with  her  person — that  she  directed  her  servant  to 
look  below  the  bedclothes,  and  that  the  attendant  on  doing  so,  found  to  her 
surprise  the  child  entirely  extruded. 

"  My  patient  assured  me  repeatedly  and  earnestly  that  she  was  quite  uncon- 
scious of  the  whole  parturient  process  culminating  in  the  birth  of  the  child,  and 
expressed  herself  both  surprised  and  alarmed  at  a  delivery  so  painless  and  in- 
stantaneous. As  she  was  daily,  nay,  hourly,  expecting  her  delivery,  it  is  but 
reasonable  to  suppose  that  she  had  been  for  some  time  acutely  alive  to  the 
earliest  intimations  of  commencing  parturition,  and  it  is  surely  remarkable  that 
nothing  occurred  from  which  she  could  have  suspected  that  the  act  had  actually 
commenced.  My  patient  had  no  object  in  deceiving  me,  and  I  am  quite  satis- 
fied of  the  entire  truthfulness  of  her  often — to  me — repeated  statement. 

"  This  case  has  a  medico-legal  significance,  as  well  as  a  practical.  If  a  female 
awake,  in  perfect  health,  in  the  exercise  of  sound  reason,  and  hourly  expecting 
her  confinement,  having  no  object  for  its  concealment,  but  many  reasons  for  its 
occurrence,  being  welcomed  by  her  friends,  can  be  the  subject  of  painless, 
unconscious  labour,  preceded  by  no  appreciable  premonitory  symptoms,  and 
making  itself  known  only  when  the  extrusion  of  the  child  has  been  completed 
in  the  way  described,  how  much  more  may  we  be  inclined  to  yield  belief  to 
cases  in  which  it  has  been  averred  that  delivery  has  taken  place  during  sleep, 
without  waking  the  mother,  and  to  others,  in  which  it  has  been  maintained  that 
owing  to  the  painlessness  of  the  parturient  process,  the  child's  life  has  been  lost 
by  a  fall  on  the  ground,  or  by  being  engulfed  in  a  latrine?  The  child  was  a 
female,  small,  but  not  much  undersized.  The  mother's  first  labour — this  was 
the  second— was  a  normal  one,  accompanied  by  the  usual  signs,  and  extending 
over  six  hours  in  its  duration." 


1863.] 


Midwifery. 


245 


Dr.  Pattison  stated  that  he  had  once  attended  a  primiparons  patient  who  suf- 
fered no  pain  at  all  during  labour.  He  had  not  been  summoned  to  the  case,  but 
happened  to  call  at  the  time  ;  the  child  was  born  quite  easily,  the  patient  only 
experiencing  a  feeling  of  pressure. 

Dr.  Wilson  had  once  been  called  to  see  a  woman  who  had  been  delivered 
without  any  pain,  whilst  she  was  walking  about  in  the  house ;  and  he  -found  the 
child  lying  on  the  floor  with  the  umbilical  cord  torn  across. 

Dr.  Cochrane  thought  that  such  a  case  as  that  related  by  Dr.  Smith  might 
more  readily  occur  in  a  warm  country  with  a  relaxing  climate.  But  he  had  him- 
self seen  a  woman  who  had  just  been  delivered  of  a  child  almost  unconsciously 
as  she  was  getting  out  of  bed. 

Dr.  Andrew  Balfour  stated  that  he  had  attended,  when  in  China,  the  wife  of 
an  engineer  on  board  a  steamer,  who  suffered  from  remittent  fever  in  the  eighth 
month  of  her  pregnancy.  The  whole  ovum  in  that  case  was  expelled  entire, 
without  any  warning ;  and  when  he  (Dr.  B.)  arrived  and  ruptured  the  sac,  the 
foetus  was  already  dead. 

Dr.  Pattison  said  Dr.  Thatcher  used  to  tell  his  class  of  a  case  where  he  found 
the  patient  had  been  delivered  of  an  entire  ovum  with  unruptured  membranes. 
Dr.  T.  had  been  summoned  by  the  husband,  who  was  in  great  dismay,  because, 
as  he  averred,  his  wife  had  given  birth  to  a  "leg  of  mutton." 

Dr.  Alex.  E.  Simpson  stated  that  Yon  Ritgen,  the  venerable  professor  of 
midwifery  at  Giessen  had  told  him,  that  in  the  long  course  of  his  practice  he 
had  met  with  no  less  than  seventeen  cases  of  labour  where  the  patient  had 
experienced  none  of  the  ordinary  labour  pains ;  and  he  (Professor  Yon  Ritgen) 
had  been  led  to  form  the  conclusion  that  in  perfectly  natural  labour,  pain  should 
not  necessarily  be  experienced,  and  that  we  had  come  to  regard  pain  as  a  natural 
and  necessary  concomitant  of  labour,  merely  because  women  were  almost  never 
in  a  perfectly  healthy  condition  when  we  were  summoned  to  aid  them  during 
parturition.  He  (Dr.  A.  R.  S.)  thought  that  if  Professor  Yon  Ritgen's  position 
could  be  established — and  the  facility  of  parturition  among  savages  went  far  to 
prove  its  truth — then  the  objection  sometimes  made  to  the  use  of  chloroform  in 
labour,  on  the  ground  of  its  being  contrary  to  nature,  would  be  most  completely 
done  away  with. — Ed.  Med.  Journ.,  Nov.  1862. 

64.  Artificial  Delivery  in  Extremis. — Details  of  an  interesting  case  of  extrac- 
tion of  the  foetus  from  the  womb  of  a  dying  woman,  by  Dr.  Belluzi,  are  given  in 
U  Union  Medicate.  In  1861,  the  doctor  relates  that  he  was  called  to  a  woman 
far  advanced  in  pregnancy,  and  in  the  last  stage  of  phthisis.  He  considered  it 
a  favourable  case  for  the  post-mortem  extraction  of  the  foetus,  as  recommended 
by  Professor  Rizzoli,  per  vaginam,  in  preference  to  the  Cesarean  section. 

On  July  11th,  the  woman's  death  seemed  rapidly  approaching,  and  the  foetal 
heart  was  distinctly  heard.  A  few  hours  later,  the  foetal  sounds  became  sensibly 
diminished  in  force ;  and  thereupon  it  was  resolved,  instead  of  waiting  for  the 
woman's  death,  at  once  to  extract  the  child,  while  both  it  and  the  mother  were 
still  alive.  The  woman  was  drawn  to  the  edge  of  the  bed,  and  her  legs  supported 
on  chairs.  "Whilst  Professor  Rizzoli  kept  the  uterus,"  writes  Dr.  Belluzi,  "in 
a  suitable  position,  I  introduced  my  right  hand,  in  the  form  of  a  cone,  into  the 
vagina,  gently  dilated  the  neck  of  the  womb,  and  at  last  felt  a  knee  of  the  foetus, 
ruptured  the  membranes,  and  brought  the  knee  down  into  the  vagina. 

"  At  the  same  time,  Professor  Rizzoli  pressed  with  his  hands  upon  the  foetus 
(through  the  walls  of  the  abdomen),  so  as  to  aid  in  imparting  to  it  the  move- 
ments which  occur  in  the  version.  This  first  stage  of  the  operation  completed, 
I  baptized  the  foetus  through  the  left  foot,  which  protruded.  Then,  on  drawing 
upon  this  limb,  a  spiral  movement  was  given  to  the  foetus,  whereby  the  nates 
were  turned  forwards  as  they  reached  the  vulva.  Immediately  afterwards,  the 
other  limb  was  protruded,  then  the  trunk,  the  shoulders,  and  the  head.  The 
child  was  alive.  The  uterus  contracted  sufficiently  to  detach  the  placenta.  The 
mother  (who,  apparently  was  insensible  to  the  operation)  was  replaced  in  bed. 
The  child  was  vigorous,  though  evidently  not  at  full  time.  It  was  taken  to  the 
Enfans-Trouv6s ;  and  two  months  later,  at  the  time  I  write,  is  still  there.  The 


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[Jan. 


operation  did  not  seem  to  have  in  any  way  injuriously  affected  the  mother.  She 
survived  it  twenty  hours.  A  post-mortem  examination  was  made  twenty-two 
hours  after  her  death.  The  uterus  was  regularly  contracted ;  and  no  injury  was 
noted,  except  a  slight  scratch  on  the  mouth  of  the  womb.  This  fact  demon- 
strates the  ease  with  which  a  living  foetus  may  be  extracted  from  a  dead  woman, 
when  no  signs  of  labour  have  appeared.  And  it  will  be  readily  admitted  that 
in  the  dying  woman  the  operation  is  as  easily  performed  as  in  the  dead.  The 
case  shows  that  we  may,  under  certain  circumstances,  rationally  resort  to  the 
forcible  extraction  of  the  foetus  before  the  death  of  the  mother,  as  thereby  we 
give  the  child  a  much  greater  chance  of  life.  In  every  case  we  should  follow 
the  rule  of  Professor  Rizzoli,  which  is,  that  the  operation  should  be  practised 
whenever  the  sounds  of  the  foetal  heart  become  enfeebled.  I  strongly  recom- 
mend this  operation  to  the  profession;  for  until  now  I  could  not  have  believed 
that  it  was  of  such  easy  execution." — Dublin  Med.  Press,  Dec.  3,  1862. 

65.  TJndescribed  Cause  of  Delay  in  Labour. — Dr.  Jas.  Sidey  related  to  the 
Obstetrical  Society  of  Edinburgh  (July  3,  1861)  the  history  of  a  case  of  tedious 
labour  that  had  lately  come  under  his  observation,  where  the  presentation  was 
natural,  and  the  pelvis  of  ordinary  dimensions,  but  the  head  remained  many 
hours  impacted  in  the  brim  before  the  pains  succeeded  in  forcing  it  through. 
After  the  birth  of  the  child,  he  had  found  the  face  to  be  unusually  broad ;  and 
on  comparing  it  with  the  measurements  of  some  other  infants  of  normal  dimen- 
sions, he  had  found  it  to  measure,  from  one  malar  protuberance  to  the  other, 
fully  a  quarter  of  an  inch  more  than  the  largest  of  the  others.  He  had  not  been 
able  to  meet  with  any  notice  of  this  increase  in  the  size  of  the  malar  bones,  as  a 
cause  of  delay  in  labour;  but  if  attention  were  directed  to  the  subject,  it  might 
prove  to  be  a  more  frequent  cause  of  tedious  labour  than  at  first  sight  we  might 
imagine. — Ed.  Med.  Journ.,  September,  1862. 

66.  Use  of  the  Forceps  in  Tedious  Labour. — Dr.  Hamilton,  of  Falkirk,  made 
a  communication  to  the  Edinburgh  Obstetrical  Society  (Nov.  27,  1861)  on  this 
subject,  and  began  by  explaining  that  he  had  first  been  led  to  the  publication  of 
the  results  of  his  obstetric  practice  in  consequence  of  a  statement  respecting  the 
mortality  of  forceps  cases,  contained  in  a  review  of  Dr.  Murphy's  work  in  the 
British  and  Foreign  Medico- Chirurgical  Review,  for  October,  1852.-  TThen 
he  (Dr.  H.)  was  first  about  to  commence  practice,  he  had  been  greatly  struck 
by  the  observation  made  by  Dr.  Reid,  who  had  probably  been  known  to  many 
of  the  Fellows  present  as  a  skilful  and  experienced  accoucheur,  to  the  effect 
that  forceps  might  be  used  in  cases  of  tedious  labour  much  more  frequently  than 
they  usually  were,  not  only  without  danger  to  the  patient  but  to  her  advantage. 
Having  found  other  trustworthy  practitioners  of  the  same  opinion,  he  (Dr.  H.) 
had  acted  on  the  hint,  and  from  the  time  when  he  first  began  to  practise,  in 
1833,  up  till  1852,  he  had  employed  the  forceps  in  a  large  proportion  of  cases  of 
labour,  and  the  results  of  his  experience  had  only  confirmed  him  in  his  opinion 
of  their  safety  and  usefulness.  He  had  then  been  astounded  at  seeing  the  state- 
ment of  Dr.  Murphy  as  to  the  great  fatality  in  forceps  cases ;  and  having  him- 
self been  under  the  impression  that  the  use  of  the  forceps  was  rather  gaining 
ground,  he  had  determined  to  investigate  the  correctness  of  conclusions  so  en- 
tirely opposed  to  those  he  had  himself  arrived  at.  "  The  question,"  as  he  had 
stated  in  a  paper  he  then  wrote  on  the  subject,  "  to  be  discussed  is  presented  to 
us  in  a  condensed  form  at  p.  422  of  the  Review  referred  to,  the  general  conclu- 
sions deducible  from  the  statistical  facts  collected  by  Dr.  Murphy  being — 1st. 
That  in  the  forceps  deliveries  occurring  in  78,892  midwifery  cases,  in  the  hands 
of  British,  French,  and  German  practitioners,  nearly  1  in  every  4  of  the  children 
was  stillborn.  2d.  That,  in  protracted  labours,  'so  far  as  the  children  are  con- 
cerned, the  proportion  stillborn  is  very  much  the  same,  whether  the  forceps  be 
employed  or  not ;  the  difference,  if  any,  being  in  favour  of  leaving  these  cases  to 
nature.'  3d.  '  That  the  use  of  instruments  is  to  be  discountenanced  in  all  but 
exceptional  cases  of  this  kind,  in  which  the  habit  of  the  patient  is  too  feeble  to 
admit  of  her  enduring  a  protracted  labour  without  risk  of  exhaustion.'  4th.  That 


1863.] 


Midwifery. 


247 


Ramsbotham  employed  the  forceps  once  in  729  cases,  Joseph  Clarke  once  in 
742,  Collins  once  in  684,  Kilian  once  in  78,  Cams  once  in  14,  Siebold  once  in  9 ; 
and  '  Dr.  Murphy's  recommendation  is  to  employ  them  only  in  cases  of  positive 
arrest,' unless  dangerous  constitutional  symptoms  are  present."  As  opposed 
to  this  high  mortality  from  the  use  of  the  forceps,  he  (Dr.  H.)  had  adduced  the 
results  of  his  own  practice,  and  had  stated  that,  whilst  using  the  forceps  in 
every  seven  or  eight  cases  of  labour,  he  had  delivered  316  children,  all  of  whom 
had  been  born  alive.  He  had  subsequently  published  an  article  in  the  Edin- 
burgh Medical  Journal,  claiming  for  the  use  of  the  forceps  the  same  continued 
immunity;  and  now  he  could  point  to  731  children  consecutively  born  alive,  in, 
the  delivery  of  from  90  to  100  of  which  the  forceps  had  been  employed.  He 
(Dr.  H.)  thought  that  this  startlingly  favourable  result  indicated  that  the  mor- 
tality which  was  usually  attributed  to  the  employment  of  the  forceps  was  rather 
due  to  the  delay  in  their  application.  He  believed  his  practice  represented  very 
fairly  that  of  a  general  country  practitioner ;  though  perhaps  now  that  he  had 
acquired  more  experience  the  proportion  of  difficult  cases  coming  under  his  care 
might  be  somewhat  above  the  average,  and  he  now  found  that  cases  which  he 
once  thought  dangerous  and  difficult  became  comparatively  easy,  simply  from 
his  constantly  following  out  the  principle  of  not  delaying  too  long  the  applica- 
tion of  the  forceps.  Remembering  the  great  law  that  the  mortality  in  parturi- 
tion increases  with  the  duration  of  the  labour,  and  believing  that  the  danger 
was  greatest  in  those  cases  where  the  delay  occurred  during  the  second  half  of 
labour,  he  was  always  anxious  to  shorten  this  stage  by  every  means  compatible 
with  the  safety  and  well-being  of  the  patient  and  her  progeny.  The  first  stage 
might  go  on  for  many  hours,  sometimes  for  days,  without  involving  the  patient 
in  any  risk,  and  he  almost  never  in  any  case  interfered  until  after  the  completion 
of  the  first  half  of  labour.  But  even  in  an  otherwise  apparently  normal  case,  if 
the  child's  head  remained  longer  than  two  hours  in  the  maternal  pelvis,  and  the 
pains  were  at  all  severe,  he  then  believed  that  the  child's  life  was  becoming  en- 
dangered, and  he  never  hesitated  in  applying  the  forceps.  He  had  now  employed 
the  forceps  in  about  200  cases,  and  found  no  danger  whatever  if  the  head  had 
not  been  allowed  to  become  impacted.  He  employed  the  forceps  in  most  cases 
as  a  direct  extractor,  but  in  some  cases  also  to  rectify  the  position.  In  one 
patient  he  had  found  it  necessary  to  employ  the  forceps  in  nine  out  of  her  twelve 
confinements,  although  her  pelvis  was  sufficiently  roomy,  in  consequence  of  the 
foetal  head  failing  to  make  the  necessary  turn  in  the  pelvis.  And  now  he  might 
be  allowed  to  state  what  he  did  not  do.  In  the  first  place,  he  now  almost  never 
used  ergot  of  rye  in  any  midwifery  case.  He  had  rarely  at  any  time  employed  it 
as  an  adjuvant  in  the  first  stage,  and  latterly  he  had  also  refrained  from  admin- 
istering it  during  the  second  portion.  He  had  no  prejudice  against  the  drug, 
but  he  had  never  been  able  to  see  that  it  fulfilled  any  good  indication  during  the 
first  stage  of  labour,  and  gradually  he  had  come  to  give  up  its  use  altogether,  so 
thatxhe  had  not  administered  it  to  one  out  of  his  last  400  parturient  patients. 
Secondly,  he  never  greased  the  forceps,  as  in  lectures  and  text-books  we  were 
instructed  to  do.  He  thought  the  greasing  unnecessary,  because  there  is  usually 
no  difficulty  in  introducing  the  instrument,  and  the  unguent  interfered  with  the 
firm  hold  of  the  foetal  head,  which  was  necessary  to  permit  of  due  tractile  force. 
When  he  first  went  to  Falkirk  he  had  attended  a  case  along  with  an  old  practi- 
tioner, where  the  patient  was  delivered  of  twins,  both  of  which  were  born  dead 
after  a  tedious  labour.  On  Saturday  last  he  had  attended  a  case  of  precisely 
the  same  kind,  where  he  did  not  doubt  that  he  would  have  had  the  same  un- 
happy result  of  producing  two  stillborn  children,  had  he  not  extracted  the  first 
child  with  the  forceps  after  its  head  had  been  but  a  short  space  of  time  on  the 
peringeum  :  as  it  was,  both  children  lived.  He  had  described  a  case  where  he 
could  not  get  the  head  of  the  child  brought  into  the  pelvis  in  a  right  direction, 
and  where,  after  long-continued  efforts  with  the  forceps  to  rectify  the  position 
of  the  head  had  failed,  in  consequence  of  its  always  turning  round  again,  he 
thought  from  the  opposition  presented  by  the  rectum,  he  had  at  last  to  perforate 
the  head  and  deliver  by  craniotomy.  He  had  recently  met  with  a  similar  case, 
where  the  head  lay  in  the  left  oblique  diameter  occipito-anteriorly,  but  could  not 
be  brought  down  into  the  pelvis  until  he  had  turned  it  by  means  of  the  forceps 


248 


Progress  of  the  Medical  Sciences. 


[Jan. 


through  three-fourths  of  the  circle  of  the  pelvic  brim,  so  that  at  last  it  presented 
occipito-anteriorly  in  the  right  oblique  diameter. 

Dr.  Hamilton  maintained  that  the  forceps  was  preferable  to  turning,  because 
he  had  seen  several  children  born  dead  where  the  latter  operation  had  been  em- 
ployed, and  in  one  case  the  vertebrae  of  the  neck  had  become  dislocated  whilst 
the  child  was  being  extracted,  so  that  delivery  could  not  be  completed  until  the 
foetal  head  had  been  opened.  He  always  used  Ziegler's  forceps,  and  usually 
applied  them  after  the  head  had  descended  so  far  into  the  pelvic  cavity  as  to 
allow  the  tip  of  the  ear  to  be  easily  felt  by  the  finger.  In  reply  to  a  question 
put  by  Dr.  Moir,  Dr.  Hamilton  repeated  that  he  had  not  had  a  single  still-birth 
among  731  children  that  he  had  delivered  successively;  and  in  reply  to  a  ques- 
tion by  Dr.  Figg,  he  (Dr.  H.)  explained  that  although  he  -had  delivered  some 
children  that  died  very  shortly  after  birth,  yet  he  did  not  count  a  child  stillborn 
if  it  continued  to  breathe,  if  only  for  five  minutes. — Edinburgh  Med.  Journ., 
Oct.  1862. 

67.  Post-partum  Hemorrhage. — Dr.  Hamilton  stated  to  the  Edinburgh  Ob- 
stetrical Society,  that  in  the  treatment  of  post-partum  hemorrhage  his  practice 
was  to  clear  out  the  clots  from  the  interior  of  the  uterus,  and  then  to  compress 
the  uterus  between  the  two  hands.  To  produce  effectual  compression  he  intro- 
duced one  hand  into  the  vagina  and  applied  it  along  the  back  wall  of  the  uterus, 
and  by  then  applying  the  other  hand  on  the  abdomen  he  could  keep  the  uterus 
flattened  between  the  two  hands  for  ten  minutes  or  a  quarter  of  an  hour,  or  three- 
quarters  of  an  hour,  or  till  such  time  as  all  tendency  to  the  recurrence  of  the 
hemorrhage  had  ceased.  The  uterus  could  be  felt  between  the  two  hands  like  a 
collapsed  India-rubber  bottle,  and  the  front  and  back  walls  could  be  held  in  most 
accurate  contact.  He  had  followed  the  practice,  and  that  of  grasping  the  mouth 
of  the  uterus,  for  above  twenty  years,  and  never  saw  a  case  where  he  could  not 
at  once  and  effectually  check  the  flooding  after  delivery. 

Professor  Simpson  remarked  that  the  practice  recommended  by  Dr.  Hamilton 
was  attended  with  this  drawback  in  some  cases,  that  the  introduction  of  the  hand 
into  the  vagina  was  occasionally  so  painful  that  the  patient  rebelled  against  it. 
In  one  case  the  patient  would  not  submit  to  the  introduction  of  the  hand  except 
on  condition  that  she  were  kept  under  chloroform.  He  preferred  to  compress 
the  uterus  through  the  abdominal  walls,  and  found  them  so  relaxed  that  he  could 
easily  pass  one  hand  behind  and  the  other  in  front  of  the  organ  so  as  to  compress 
it  between  them—  Ed.  Med.  Journ.,  Oct.  1862. 

68.  New  Transfusion  Apparatus. — Dr.  Hamilton  exhibited  to  the  Edinburgh 
Obstetrical  Society  an  apparatus  which  he  had  contrived  for  the  performance  of 
transfusion,  and  gave  the  following  account  of  it : — 

The  method  of  treating  post-partum  hemorrhage,  which  I  have  described  in 
the  last  October  number  of  the  Edinburgh  Medical  Journal,  furnishes  to  the 
practitioner  a  simple,  and,  as  far  as  my  experience  for  upwards  of  twenty  years 
in  its  use  enables  me  to  speak,  a  certain  and  immediate  means  of  restraining 
this  affection.  I  have  said,  however,  that  even  where  this  is  done  at  once  and 
effectually,  death  may  take  place  from  the  drain  of  blood  having  already  been 
so  great,  or  so  rapid,  that- the  system  is  unable  to  rally,  notwithstanding  the  use 
of  all  the  common  appliances.  Two  years  since,  I  met  with  a  painful  case  of 
this  kind.  Returning  from  the  country  about  two  o'clock  one  afternoon,  I  was 
told  that  urgent  messages  had  been  left  for  me  to  see  a  patient  in  the  town, 
whom  I  found  with  all  the  usual  symptoms  of  extreme  depression  from  flooding. 
A  midwife  had  delivered  her  some  hours  previously,  and  a  brother  practitioner 
in  my  absence  had  also  seen  the  woman.  I  instantly  extracted  from  the  uterus 
a  moderate-sized  clot  of  blood,  and  applied  compression  with  both  hands,  in  the 
wax  I  have  explained  in  the  article  referred  to,  so  that  I  was  certain  no  more 
blood  was  lost.  Notwithstanding  this  being  done,  and  also  pouring  into  the 
patient  an  abundance  of  stimulants,  the  urgent  symptoms  continued  to  increase, 
so  that  about  3  P.  M.  her  case  was  becoming  desperate.  I  therefore  resolved, 
with  the  assistance  of  my  professional  brother,  to  attempt  staying  the  fatal 
result  by  transfusion.    My  transfusing  apparatus  was  not  in  such  exact  working 


1863.] 


Midwifery. 


249 


order  as  to  give  me  perfect  confidence  in  operating  with  it ;  and,  while  getting 
this  remedied,  about  half  an  hour  was  lost,  and  the  patient  sunk.  I  have  seen 
and  heard  of  a  good  number  of  such  cases  in  my  own  neighbourhood,  and  quite 
recently  a  lady  under  my  care  very  nearly  lost  her  life  from  an  insidious  flood- 
ing of  about  four  hours'  duration.  These  distressing  cases  determined  me,  when 
next  similarly  called  upon  to  act,  to  have  my  transfusing  apparatus  in  working 
condition,  and  especially  to  have  the  syringe  in  such  a  state  as  to  secure  me 
from  the  risk  of  pumping  air,  instead  of  blood,  into  the  patient.  I  was  not  very 
much  encouraged  by  the  trials  I  made  on  this  subject,  and  I  at  first  thought  of 
connecting  with  the  tube  leading  from  the  syringe  a  glass  trap,  to  catch  bubbles 
of  air,  if  they  should  by  accident  get  mixed  with  the  blood ;  and,  thinking  more 
upon  the  subject.  I  asked  myself  whether  there  existed  any  necessity  for  a 
syringe  at  all.  The  result  was,  the  construction  of  the  simple  little  instrument 
which  I  now  exhibit.  It  consists  of  a  funnel  for  receiving  the  blood,  say  four 
inches  broad  at  the  mouth,  with  a  stop-cock  attached  to  it;  of  a  small  tube,  for 
introduction  into  the  vein  of  the  patient,  also  having  a  stop-cock  attached  to  it; 
and  of  an  India-rubber  tube,  two  feet  long,  for  connecting  the  two.  In  operat- 
ing with  this  instrument,  I  propose  that  the  patient  should  be  placed  at  a  lower 
level  than  the  person  from  whom  the  blood  is  to  be  drawn,  so  that  we  may  have, 
1st.  The  force  of  gravitation  to  impel  the  blood  forwards;  and,  2d.  That  we 
may  thus  effectually  provide  for  the  non-entrance  of  air  into  the  veins,  as  the  air, 
being'the  lighter  body,  must  always  keep  on  the  surface.  In  order  to  test  the 
practical  working  of  this  instrument,  I  got  two  dogs,  upon  which  I  performed 
a  few  experiments.  Having  heated  the  instrument,  by  pouring  warmish  water 
through  it,  in  the  first  experiment  I  opened  the  jugular  vein  of  the  dog  from 
which  the  blood  was  to  be  taken,  and  allowed  the  blood  to  issue  from  the  tubule 
before  this  was  introduced  into  the  same  vein  of  the  other  dog.  I  did  this  in 
order  to  expel  the  air,  but  found  that,  during  the  time- thus  lost,  the  blood  in  the 
funnel  and  tube  had  coagulated.  In  my  next  experiment  I  avoided  the  chance 
of  this  happening,  by  filling  the  tube  and  the  lower  portion  of  the  funnel  with 
warmish  water,  introducing  the  tubule  into  the  vein,  and  then  opening  the  vein 
of  the  dog  from  which  the  blood  was  to  be  drawn.  In  this  way  a  small  quantity 
of  the  blood  ran  off,  but  still  coagulation  took  place  too  rapidly  to  make  the 
experiment  satisfactory.  In  my  third  experiment  I  used  simply  luke-warm 
water,  an'd  then  I  found  I  could  with  ease  inject  any  quantity  I  desired.  I  now 
tried  the  action  of  the  apparatus  with  human  blood.  I  first  filled  it,  as  before, 
with  luke-warm  water,  and  shut  the  stop-cocks;  and,  just  before  opening  the 
vein  of  the  patient,  emptied  out  the  whole  except  what  remained  in  the  tube  and 
bottom  of  the  funnel,  which'I  afterwards  found  amounted  to  about  two  drachms. 
As  soon  as  two  or  three  drachms  of  blood  had  been  drawn,  I  opened  both  stop- 
cocks, and  allowed  it  to  run  off,  and  I  found  that  it  ran  in  a  continuous  stream 
into  a  plate,  until  I  had  obtained  the  quantity  I  wished  to  abstract,  viz.,  about 
eighteen  ounces.  I  found  that,  by  regulating  the  stop-cock  connected  with  the 
funnel,  I  could,  with  great  ease,  keep  only  a  few  drachms  in  the  funnel,  thus 
making  the  transfer  from  the  patient  to  the  plate  almost  immediate.  I  repeated 
this  experiment,  with  exactly  the  same  result :  the  blood  in  the  plate  presenting 
next  day,  as  far  as  I  could  judge,  precisely  the  same  appearance  as  if  it  had  been 
drawn  direct  from  the  patient.  I  find  that  water  falls  through  the  whole  length 
of  the  tube  in  about  2^  seconds,  and  an  ounce  of  water  runs  off  from  the  funnel 
in  8  seconds,  so  that  the  exposure  of  the  blood,  where  the  stream  is  kept  con- 
tinuous, musfrbe  very  trifling,  and  probably  will  be. found,  when  the  instrument 
used  is  made  entirely,  or  chiefly,  of  non-conducting  materials,  neither  to  lower 
its  temperature  much,  nor  to  alter  unfavourably  its  vital  properties.  Combining 
the  results  of  the  two  sets  of  experiments,  there  seems  to  be  little  reason  to 
doubt  that  transfusion  of  blood,  or  injection  of  water  or  other  fluids,  might  with 
ease  be  effected  with  this  instrument  in  the  human  subject,  or  in  animals. 
Transfusion  with  dog's  blood  is  much  more  difficult  than  where  human  blood  is 
employed.  Dr.  Blundell  found  that  the  first  coagulates  in  10  seconds,  whereas 
the  latter  takes  60  seconds  to  coagulate ;  and  hence,  no  doubt,  the  reason  why 
he  employed. human  blood  to.  transfuse  into  dogs. 
My  feeling  is,  that  many  lives  are  annually  lost,  in  obstetric  practice  alone, 


250 


Progress  of  the  Medical  Sciences. 


[Jan. 


from  loss  of  blood ;  and,  looking  at  the  recorded  cases,  I  have  seen  in  which 
transfusion  had  been  employed,  it  seems  to  me  that  they  offer  great  encourage- 
ment to  its  more  frequent  use.  The  great  obstacles  I  think  hitherto  to  using 
it  have  been,  the  complexity  and  expense  of  the  apparatus  used,  the  dread  of 
introducing  air  in  dangerous  quantities  into  the  veins  from  the  use  of  the 
syringe,  and  timidity  on  the  part  of  the  surgeon,  from  want  of  dexterity  or  want 
of  practice,  in  performing  the  operation.  If  my  anticipations  be  correct,  such 
an  instrument  as  I  have  exhibited  may  remove  the  two  former  obstacles,  for  it 
is  so  simple,  that  it  can  with  the  greatest  ease  be  cleaned  and  kept  in  order ;  it 
will  cost  only  a  few  shillings,  and  could  therefore  be  in  every  practitioner's  pos- 
session ;  and,  with  the  most  ordinary  care,  it  renders  impossible  the  entrance 
of  air  into  the  veins.  As  to  the  third  obstacle  I  have  mentioned,  practitioners 
could  easily  remove  it  by  performing  a  few  experiments  on  dogs,  with  water 
instead  of  blood  :  the  injection  of  a  moderate  quantity  at  a  proper  temperature 
apparently  doing  them  no  harm.  I  will  only  add  the  usual  caution  given  in  these 
cases,  that  the  experimenter  be  careful  to  expose  properly  the  vein  before  incis- 
ing it,  otherwise  he  will  run  great  risk  of  injecting  the  fluid  into  the  cellular 
tissue,  instead  of  the  vein.  I  was  assisted  in  my  experiments  by  Mr.  Heriot, 
veterinary  surgeon,  Falkirk,  who  secured  the  dogs,  and  applied  the  ligature  to 
"  start"  the  vein.  After  shaving  off  the  hair,  I  pinched  up  the  skin  over  the 
vein  with  my  left  thumb  and  forefinger,  made  an  incision  with  a  sharp  curved 
bistoury  in  the  course  of  the  vein,  gently  dissected  the  cellular  tissue  from  the 
ve^n,  and  then  opened  it. 

After  I  had  made  the  experiments  I  have  detailed,  I  found,  on  consulting  Dr. 
Blundell's  paper  on  Transfusion,  and  his  Principles  of  Midwifery,  published  in 
1839,  that  he  also  had  the  idea  that  an  instrument  of  a  simple  kind  might  be 
used  in  transfusion  instead  of  the  syringe,  but,  curiously  enough,  he  seems  never 
to  have  constructed  or  employed  it.  In  his  Principles  of  Midwifery  (p.  255), 
he  says,  "  transfusion  from  artery  to  vein,  or  perhaps  even  from  vein  to  vein, 
might  be  accomplished  by  tubule  simply ;"  that  is,  as  I  understand  it,  by  con- 
necting the  two  together ;  and  again,  "  a  fall  of  two  or  three  inches,  perhaps 
less,  is  sufficient  to  move  by  gravitation  the  blood  into  the  vein."  Dr.  Blundell 
proposes  to  call  this  a  "  gravitator,"  and  the  name  seems  a  very  appropriate  one 
both  for  his  and  my  own  instrument.  Instead  of  two  or  three  inches  of  a  fall, 
however,  I  think  that  in  my  instrument  great  advantage  will  result  from  having 
the  India-rubber  tube  two  feet  in  length,  as  this  both  gives  facility  in  adapting 
the  instrument,  and  furnishes  no  more  than  enough  of  gravitating  power  for  pro- 
pelling the  fluid,  as  a  substitute  for  the  syringe.  It  seems  to  me,  however,  that 
quite  sufficient  force  can  be  thus  acquired  for  what  is  wanted,  of  a  kind,  too, 
somewhat  like  the  equable  gentle  force  employed  by  nature  in  the  venous  circu- 
lation ;  and  that,  until  coagulation  takes  place,  there  need  be  little  fear  of  the 
flow  of  blood  keeping  continuous.  If  coagulation  has  taken  place,  any  exertion 
of  force  with  a  syringe  or  otherwise  would  only,  I  think,  be  likely  to  do  harm, 
by  propelling  coagula  into  the  veins.  In  such  a  case,  much  the  best  plan,  I 
think,  would  be  at  once  to  remove  the  instrument,  clean  it  out,  and  reapply  it. 

In  transfusing  in  the  human  subject,  I  would  be  inclined  to  proceed  in  the 
same  way  as  I  did  in  my  second  experiment  on  the  dogs.  Filling  the  instrument 
with  water  of  the  proper  temperature,  and  introducing  the  tube  into  the  vein  of 
the  patient,  before  the  supplying  vein  is  opened,  will  both  prevent  any  material 
abstraction  of  heat  from  the  blood,  and  will  also  obviate  the  risk  of  coagulation, 
should  any  unexpected  delay  occur.  The  two  drachms  of  water  that  would 
thus  be  first  introduced  into  the  veins,  would  probably  be  beneficial  rather  than 
otherwise.  .  * 

In  the  instrument  I  have  used,  the  two  stop-cocks  and  the  tube  to  introduce 
into  the  vein  are  metallic ;  but  Messrs.  Thornton  inform  me,  that  these,  as  well 
as  the  funnel,  could  be  made  of  vulcanite,  one  of  the  best  materials  I  know  of 
for  such  a  purpose,  being  both  a  good  non-conductor  of  heat,  and  little  liable  to 
alteration  of  its  surface.  Any  one  wishing  to  possess  such  an  instrument  may 
obtain  it  by  applying  to  Messrs.  Thornton,  India-rubber  Warehouse,  Princes 
Street,  Edinburgh. — Ed.  Med.  Juurn.,  Oct.  1862. 


1363.] 


Midwifery. 


251 


69.  Repeated  Twin  Births. — J.  L.  Brittain  communicated  to  the  Edinburgh 
Obstetrical  Society  the  following  case  of  frequent  twin  pregnancy,  which  oc- 
curred in  the  practice  of  his  father  : — 

"Mrs.  J.,  ret.  47,  was  first  pregnant  at  the  age  of  25.  She  has  had  14  preg- 
nancies and  25  children,  having  had  twins  11  times.  Of  the  11  cases  of  twins, 
in  8,  both  children  were  born  at  the  full  time  ;  in  2,  one  foetus  was  aborted  about 
the  third  month,  the  other  being  carried  to  the  full  time  ;  and  in  one,  she  mis- 
carried both  at  the  fourth  month. 

"  Of  the  8  cases  in  which  the  children  were  born  at  the  full  term,  the  sex  was 
boy  and  girl,  5  times ;  both  girls,  twice ;  both  boys,  once. 

"  In  the  miscarriage  case  they  were  boy  and  girl ;  in  the  first  case  of  miscarry- 
ing, one  of  the  two,  a  girl  was  aborted,  a  boy  bora  at  full  time ;  in  the  second,  a 
boy  was  aborted,  and  another  carried. 

"  Mrs.  J.'s  mother  had  twins  once ;  but  she  never  heard  of  another  instance 
in  either  her  or  her  husband's  family. 

"  Mrs.  J.  was  delivered — 

Presentation. 

1839,  Sept.    9,  Boy  and  Girl.     Full  time.  Both  head. 

1S40.  July  — ,  Girl.  Four  months.     Not  observed. 

1841,  Jan.   12,  Bov.1  Fulltime.  Head. 

1842,  Nov.  22,  Girl.  Fulltime.  Head. 

1843,  July  — ,  Bov  and  Girl.     Four  months.     Not  observed. 

1844,  July  21,  Boy  and  Girl.     Fulltime.  Both  head. 

1845,  July     3,  Bov  and  Girl.  "  Both  head. 

1847,  April  10,  Boy  and  Girl.  "  1st,  foot;  2d,  head. 

1849,  July  26,  Boy.  "  Head. 

1851,  Jan.   24,  Girl  and  Girl.  "  1st,  head;  2d,  foot. 

1852,  May     7,  Girl  and  Girl.  "•  1st.  breech;  2d,  foot. 

1853,  Aug.    2,  Girl.  "  Head. 

1854,  Aug.  17,  Bov  and  Boy.  "  Both  head. 

1855,  Nov.  17,  Boy.  "  Head. 
(And  miscarried  a  boy  in  April.) 

1857,  April   6,  Boy  and  Girl.  "  1st,  foot;  2d,  head. 

"  All  at  full  time  born  alive.  Some  died  within  twelve  months,  some  in  a  few 
years :  and  there  are  several  alive  and  strong." — Ed.  Med.  Journ.,  Nov.  1862. 

70.  Extra  Uterine  Pregnancy. — Br.  Brandt,  of  Madeira,  presented  to  the 
Obstetrical  Society  of  Edinburgh  (November  13, 1861)  the  following  notes  of  a 
curious  case  of  extra  uterine  conception  :  Francisca  Amelia  Vieira  was  born  in 
the  island  of  Madeira  in  the  year  1778.  Was  married  to  Alexander  Yieira  in 
1795.  Was  confined  of  her  first  child  (a  son)  on  the  20th  of  September,  1796, 
who  died  in  London  on  the  31st  March,  1802,  aged  five  years,  six  months,  and 
ten  days.  Five  years  after  the  first  confinement  she  had  a  daughter  named 
Maria,  who  was  baptized  at  home,  and  died  soon  after.  Three  years  after  this 
she  became  in  the  family  way,  but  was  never  confined  of  it.  Four  years  after 
she  was  confined  of  a  son  named  Ernesto,  who  is  still  living  in  Italy;  still  re- 
maining in  the  family  way  of  the  third  child.  Seven  years  after  the  birth  of 
Ernesto,  she  was  confined  of  a  daughter,  who  is  also  still  living,  called  Amalia 
Augusta  Yieira.  She  died  on  the  7th  September,  1858.  On  the  8th  September, 
1858,  at  8  o'clock  A.  M.,  the  postmortem  examination  was  made  on  the  body 
of  Francisca  Amelia  Yieira,  in  the  presence  of  Dr.  Juvenal  Osorio  de  Ornellas, 
Surgeons  Joao  Nepomeceno  Gomez  and  Francisco  Simplicio  Lomelino,  Henry 
Crawford,  the  head  nurse,  several  students  and  chemists,  and  the  servants  of 
the  hospital.  A  bony  tumour  was  extracted  from  the  abdomen,  on  the  right 
side  of  the  uterus  in  the  Fallopian  tubes  of  that  side ;  the  uterus,  and  Fallopian 
tubes  on  the  left  side  were  perfect.  The  tumour  weighed  4  pounds,  was  8  inches 
in  length.  54  inches  in  diameter,  and  16  inches  in  circumference.  The  tumour 
was  divided  longitudinally  with  a  saw,  as  near  the  centre  line  as  possible. 


1  Within  six  months  after  the  last. 


252 


Progress  of  the  Medical  Sciences. 


[Jan. 


The  two  parts  of  the  tumour  which  I  saw  in  April,  1861,  were  very  much  dis- 
figured, being  badly  preserved  in  a  dry  state,  and  almost  crumbling  to  pieces. 
Francisca  Amelia  Yieira  was  born  in  1778. 

Married  in  1795  ...  17  years  old. 

First  child  "  1796  ...  18       "  Son. 

Second  child  "  1801  ...  23       "  Daughter. 

Pregnant  "  1804  ...  26       "        Not  born. 

Third  child  "  1808  ...  30       "        Son  living. 

Fourth  child  "  1815  ...  37       "        Daughter  living. 

Died  "  1858  ...  80 

Was  pregnant  of  the  third  conception  fifty-four  years. 

The  tumour  or  bony  cyst  contained  a  foetus,  which,  from  certain  signs  which 
will  hereafter  be  mentioned,  must  have  lived  a  long  time  after  the  natural  term 
of  birth.  Its  position  iu  the  bony  case  was,  head  uppermost,  looking  to  the  left 
and  downwards,  spine  and  back  lying  against  the  right  side  of  the  cavity,  the 
nates  occupied  the  inferior  part  of  the  cavity,  the  thighs  and  legs  turned  up,  so 
that  the  feet  were  next  the  head;  the  whole  body  was  twisted.  It  so  happened 
that  the  saw  cut  through  the  head  and  body,  dividing  it  through  the  median 
line;  but  as  the  body  was  twisted,  the  section  could  not  show  two  equal  sides. 

The  head,  in  consequence  of  the  pressure  exercised  on  it  by  the  cyst,  was 
crushed  in  such  a  way  that  the  parietal  bones  passed  over  the  occipital  and  part 
of  the  left  temporal  bones,  and  under  the  posterior  border  of  the  frontal  bone ; 
from  appearances  the  whole  of  the  cranium  was  ossified. 

The  upper  jaw  of  the  larger  half  of  the  head  has  three  teeth,  one  of  which 
appears  to  be  the  second  molar ;  the  depressions  of  these  teeth  can  be  seen  on 
the  corresponding  side  of  the  other  half  of  the  head. 

The  two  inferior  extremities  and  the  right  arm  and  hand  are  placed  between 
the  right  side  of  the  head  and  the  parietes  of  the  cyst,  in  a  very  compressed 
state.  The  left  arm  and  hand  are  situated  on  the  opposite  side  of  the  head, 
between  this  and  the  corresponding  side  of  the  cyst,  also  in  a  compressed  state. 

Part  of  the  umbilical  cord  can  be  traced  round  the  neck,  along  the  right  side 
of  the  face  and  body,  with  the  inferior  members,  to  the  navel.  The  instep  of  the 
left  foot  is  placed  against  the  chin  and  mouth,  there  forming  a  depression.  From 
the  different  positions  of  parts  above  mentioned,  it  is  clear  that  the  whole  body 
from  the  neck  downwards  is  twisted  from  left  to  right,  and  the  inferior  members 
are  turned  upwards  along  the  right  side  of  the  trunk. 

The  right  knee  lies  on  the  mastoid  process  (right) ;  the  right  foot  lies  in  the 
following  way:  External  border  on  sutura  sagittalis.  Heel,  on  the  molar  bone, 
right  side.  Sole,  part  on  the  right  side  of  the  frontal,  and  part  on  the  temporal 
bone  (right).  The  left  femur,  which  was  cut  longitudinally  by  the  saw,  presents 
a  small  medullar  cavity;  the  compact  tissue  is  extremely  hard,  and  has  the 
appearance  of  ivory  (eburne).  On  the  condyles  of  the  tibia  can  be  seen  remains 
of  the  epiphysarian  cartilage;  the  left  omoplate,  which  was  also  sawed,  is  ex- 
tremely hard.  The  liver  is  excessively  large  ;  part  of  the  intestines  are  visible. 
— Ed.  Med.  Journ.,  September,  1862. 

71.  Extra  Uterine  Fostation  :  Tlie  Foetus  in  the  Sac  of  the  Hernia. — An  in- 
stance of  this  extraordinary  and  probably  unique  occurrence  is  related  by  Herr 
W.  Miiller,  a  surgeon  of  Hohenweihr.  The  woman  was  a  strong  person,  aged 
38,  accustomed  to  very  hard  physical  labour,  in  consequence  of  which  she  had 
become  affected  with  an  inguinal  hernia  of  the  right  side.  Under  these  circum- 
stances she  ceased  to  menstruate,  and  began  to  experience  all  the  signs  of  preg- 
nancy, except  that  the  belly  did  not  enlarge.  The  hernial  tumour,  however, 
steadily  increased  in  size,  and  on  M.  Muller's  first  visit  to  the  patient  he  could 
detect  by  means  of  the  stethoscope  a  sound  exactly  answering  in  character  to  a 
placental  murmur.  The  diagnosis  of  a  living  extra-uterine  foetus  was  confidently 
made,  and,  as  the  woman  was  at  full  term,  an  operation  was  proposed  and  as- 
sented to.  An  incision  having  been  carefully  made  into  the  sac,  the  foetus  was 
cautiously  extracted,  and  found  to  be  of  full  development  and  healthy.  The 
cord  was  tied  in  the  ordinary  way,  and  divided.    The  superficial  hemorrhage 


1863.] 


Midwifery. 


253 


was  easily  arrested,  the  placenta  removed,  and  a  compress  applied,  when  the 
patient  was  observed  to  become  silent  and  pale ;  and  the  signs  of  an  internal 
hemorrhage  developed  themselves.  In  spite  of  remedies  the  woman  sank  one 
hour  after  the  conclusion  of  the  operation.  Chloroform  was  used  in  the  per- 
formance of  the  latter.  Unfortunately  no  necroscopic  inspection  of  the  body 
could  be  obtained,  as  the  friends  had  religious  scruples  on  the  subject. — Lond. 
Med.  Eev.,  Oct.  1862,  from  Allgemeine  Wiener  Med.  Zeitung. 

72.  Retroversion  of  Pregnant  Uterus. — Dr.  Beuce  read  before  the  Edinburgh 
Obstetrical  Society  the  following  case  of  this :  "  On  the  24th  of  March  last,  I 
was  sent  for  to  see  Mrs.  GT.,  and  on  visiting  her  I  found  her  condition  to  be  as 
follows :  She  is  an  unhealthy  woman ;  one  arm  is  almost  useless ;  pieces  of  bone 
have  come  out  of  it,  and  others  will  probably  follow.  She  has  an  anxious 
expression  of  countenance,  and  complains  of  frequent  efforts  to  bear  down,  and 
of  difficult  micturition.  She  had  been  troubled  with  prolapsus  uteri  for  some 
time  before,  which  condition  disappeared,  and  then  the  above  symptoms  super- 
vened. These  had  existed  for  several  days  before  I  saw  her,  and  she  had  sent 
for  a  midwife,  thinking  she  was  about  to  miscarry.  She  thought  she  was  preg- 
nant, not  having  menstruated  for  three  months  previously.  Her  abdomen  was 
very  much  enlarged,  as  much  so  as  at  a  considerably  advanced  period  of  preg- 
nancy. General  treatment  was  had  recourse  to  for  a  time,  but  only  With  partial 
and  temporary  benefit. 

"On  making  a  vaginal  examination  then,  I  failed  to  discover  the  os  uteri,  and 
could  only  feel  a  tumour  of  considerable  size,  supposed  to  be  the  uterus  much 
enlarged.  No  improvement  taking  place,  on  the  contrary,  the  patient  becoming 
worse,  and  the  bearing  down  more  severe,  I  made  a  further  examination,  and, 
on  pressing  up  as  far  as  possible  to  try  and  reach  the  os,  a  gush  of  liquid  came 
away,  and  the  patient  expressed  herself  at  once  as  being  much  relieved,  while 
there  was  a  corresponding  reduction  in  the  size  of  the  abdomen — the  walls  of 
which  were  previously  quite  tense  becoming  much  more  yielding.  This  amelio- 
ration, however,  did  not  continue  long,  as  next  day  matters  were  much  the  same 
as  before;  the  fluid  having  reaccumulated. 

"  On  repeating  the  examination,  and  pressing  upwards  as  before,  more  fluid 
came  away  just  as  on  the  former  occasion,  and  with  the  same  effect  of  affording 
relief  to  her  symptoms  ;  but,  as  at  the  former  examination,  I  was  unable  to  touch 
the  os  uteri.  The  fluid  continued  to  flow  in  large  quantities,  rendering  the  patient 
very  uncomfortable.  The  urine  was  drawn  off  several  times,  but  there  was  no 
great  accumulation  of  it. 

"  At  this  period  of  the  case  Dr.  Keiller  saw  the  patient  along  with  me,  and 
was  equally  unsuccessful  in  reaching  the  os.  He  agreed  with  me  in  thinking 
that  the  uterus  must  be  retroverted,  and  recommended  that  the  patient  should 
be  removed  to  the  infirmary,  when  he  would  give  chloroform  and  introduce  the 
hand  into  the  vagina,  so  as  to  make  a  thorough  examination,  and  remedy  the 
condition  if  possible.  1  may  state  that  every  attempt  at  examination  brought 
on  very  severe  bearing-down  efforts.  After  taking  some  time  to  consider,  she 
made  up  her  mind  to  go  to  the  infirmary,  and  on  the  22d  of  April  she  placed  herself 
under  Dr.  Keiller's  care.  She  was  then  brought  under  the  influence  of  chloro- 
form, and  Dr.  Keiller  having  introduced  his  hand  well  in,  was  enabled  to  feel 
the  os  tilted  high  up,  and  now  the  excessive  bearing-down  was  well  seen,  the 
uterus  being  forced  down  in  a  very  extraordinary  manner,  and  pressing  strongly 
upon  the  perineum,  just  like  the  child's  head  during  the  strong  expulsive  pains 
before  delivery  ;  it  could  be  compared  to  nothing  else.  Dr.  Keiller  now  by  mani- 
pulating (drawing  down  the  os  with  his  thumb,  and  pushing  up  the  body  of  the 
uterus  with  his  fingers),  was  successful  in  replacing  the  organ  in  its  normal 
position,  the  mass  going  up  with  a  jerk,  immediately  upon  which  the  tumour 
disappeared,  and  the  os  was  found  to  occupy  its  proper  place.  A  little  blood 
came  away  during  the  operation.  Next  day  the  patient  expressed  herself  as 
being  greatly  relieved,  the  bearing-down  pains  having  entirely  ceased,  and  her 
countenance  betokening  how  much  easier  she  was.  The  existence  of  pregnancy 
was  not  decidedly  made  out,  for  if  she  had  been  in  this  condition  we  would  have 
expected  labour  to  be  induced  by  the  treatment  she  was  subjected  to,  particu- 


254 


Progress  of  the  Medical  Sciences. 


[Jan. 


larly  after  the  escape  of  the  liquor  amnii,  but  nothing  of  the  kind  occurred. 
She  remained  in  the  infirmary  for  some  time  subsequently,  being  very  weak,  and 
some  small  portions  of  bone  were  removed  from  the  arm;  but  before  she  left  the 
sounds  of  foetal  heart  were  distinctly  made  out.  In  the  month  of  August  I  saw 
this  patient  going  about  comparatively  well,  and  expecting  her  confinement  in 
a  month  or  two.  I  afterwards  ascertained  that  she  was  delivered  on  the  25th 
September  of  a  living  and  healthy-looking  child,  and  made  a  very  good  recovery." 
— Edinburgh  Med.  Journal. 

73.  Dr.  Hodge's  Pessary  for  Retroversion  of  the  Uterus. — Dr.  Chuechill  ex- . 
hibited  to  the  Dublin  Obstetrical  Society,  specimens  of  a  pessary  for  retroversion, 
invented  by  Dr.  Hodge,  of  Philadelphia.  Each  pessary  consisted  of  an  upright 
and  a  horizontal  portion ;  the  former  to  occupy  the  vaginal  cul-de-sac  behind  the 
cervix  uteri,  whilst  the  latter  portion  lies  along  the  vagina  to  the  arch  of  the 
pubis.  Dr.  Churchill  reminded  the  society  that  some  years  ago  he  exhibited  a 
pessary  constructed  for  the  purpose  of  distending  upwards  the  posterior  cul-de- 
sac,  but  differing  in  form  from  Dr.  Hodge's.  After  trying  both,  Dr.  Churchill 
pronounced  his  experience  to  be  entirely  in  favour  of  Dr.  Hodge's  instrument, 
and  he  begged  to  recommend  it  to  the  society.  He  had  tried  it  in  ordinary  cases 
of  retroversion ;  and  in  one  extremely  difficult  case,  and  with  remarkable  bene- 
fit. It  occasions  no  irritation,  absolutely  precludes  the  retroversion  when  pro- 
perly fitted,  and  will  materially  aid  in  raising  the  fallen  womb  when  it  cannot  be 
at  once  reduced. — Dublin  Quart.  Journ.  Med.  Sci.,  Aug.  1862. 

74.  The  Changes  of  Body-weight  in  Pregnant,  Parturient,  and  Puerperal 
Women. — Dr.  Gassner  availed  himself  of  his  residence  in  the  Lying-in  Hospital 
of  Munich  to  institute  an  extended  series  of  observations  on  the  variations  in 
body-weight  of  pregnant  and  lying-in  women.  His  observations  appear  to  have 
been  made  with  every  care  to  avoid  fallacy.  His  memoir  contains  a  number  of 
tables,  in  which  the  results  are  detailed  and  classified.  We  can  only  here  give 
some  of  the  conclusions: — 

Pregnancy. — During  the  last  three  months  the  body  increases  in  substance, 
and  so  remarkably  that  the  gain  cannot  be  explained  by  the  growth  of  the  ovum 
alone.  The  maternal  organism  shares  in  the  increase.  A  diminution  of  weight 
is  pathological.  The  increase  of  the  body-mass  during  the  period  named  is  a 
thirteenth  part  of  the  body. 

Primiparae  do  not  gain  so  much  in  proportion  as  multipara?. 

The  intra-uterine  retention  of  a  dead  foetus  is  constantly  attended  by  a  con- 
siderable loss  of  the  maternal  body-mass.  This  circumstance  may  come  in  aid 
to  diagnosis,  when  auscultation  no  longer  detects  sounds  of  foetal  heart. 

Labour. — The  loss  of  weight  following  labour  is  on  an  average  nearly  the 
ninth  part  of  the  body-weight  of  a  pregnant  woman  who  has  reached  the  end 
of  the  tenth  month.  It  is  constituted  of  the  expelled  ovum,  blood  excrements 
voided  during  labour,  and  the  lung  and  skin  exhalations. 

The  weight  of  the  entire  ripe  ovum,  foetus,  liquor  amnii,  and  placenta  is  about 
the  10.8  part  of  the  body-weight  of  the  woman  in  labour. 

The  mass  of  the  several  parts  of  the  ovum  at  the  end  of  pregnancy  may  be 
stated  as  follows  : — 

The  weight  of  the  child  :  to  weight  of  the  ovum  =  1  :  1.755 

liquor  amnii  :  "  "  =  1  :  3.070 

placenta      :  "  =  1  :  9.600 

The  weight  of  the  ovum  and  of  its  components — that  is,  of  the  child,  liquor 
amnii,  and  placenta,  is  in  proportion  to  the  body-weight  of  the  mother. 

The  mature  ovum  of  the  primipara  is  smaller  than  that  of  the  multipara. 

The  quantity  of  the  amniotic  fluid  increases  during  the  latter  three  months  of 
pregnancy. 

In  all  cases  where  a  change  of  position,  or  a  culbute  of  the  child,  took  place 
in  utero,  a  disproportional  increase  of  liquor  amnii  was  present. 

The  size  of  the  periphery  of  the  abdomen  at  the  end  of  pregnancy  is  in  direct 
proportion  to  the  sum  of  the  body-weight  of  the  pregnant  woman.  This  should 
be  borne  in  mind  in  estimating  the  question  of  twins. 


1863.] 


Midwifery. 


255 


Puerpery. — The  loss  of  weight  during  the  first  eight  days  of  the  labour,  occa- 
sioned by  excretions,  secretions,  especially  of  the  lochia  and  milk,  increased 
excretion  of  urine,  and  the  involution  of  the  genitals,  is  on  an  average  the 
twelfth  part  of  the  mother's  body.  This  loss  is  the  greater  in  proportion  to  the 
proximity  of  the  labour  to  the  normal  term  of  gestation. 

In  primiparse  and  in  women  who  do  not  suckle,  this  loss  is  somewhat  less  than 
in  pluriparse  and  suckling  women. 

The  loss  is  in  direct  proportion  to  the  quantity  of  the  body-mass  of  the  lying-in 
woman. 

The  surprising  loss  of  weight  on  the  first  day  of  childbed  is  due  to  the  increased 
secretion  of  urine  resulting  from  the,  resorption  of  the  serous  infiltration  which 
took  place  during  pregnancy,  to  the  more  copious  lochial  discharge,  and  to  the 
scarcely  ever  failing  sweat. 

The  loss  of  weight  due  to  labour  and  childbed  amounts  on  an  average  to  the 
fifth  part  of  the  body-weight  of  the  pregnant  woman. — Brit,  and  For.  Med.- 
Chir.  Review,  Oct.  1862,  from  Man./.  Geburtsk,  January,  1862. 

75.  Tlie  Organic  Connection  of  the  Fallopian  Tube  with  the  Ovary. — Dr. 
Panck,  relying  upon  comparative  anatomy  and  observations  on  the  human  sub- 
ject, submits  that  the  adhesion  of  the  orifice  of  the  Fallopian  tube  with  the  ovary 
at  the  time  of  conception,  takes  place  through  a  newly-formed  membrane,  which 
at  a  later  period  is  absorbed.  He  examined  the  body  of  a  girl  who  had  died 
shortly  after  conception,  and  found  a  delicate  new  membrane,  which  fastened 
the  fringes  of  the  tube  to  the  ovary.  In  subsequent  researches  Dr.  Panck  found 
a  similar  membrane  so  frequently  as  34  times  out  of  58  cases,  but  only  in  women 
who  had  borne  children,  and  only  on  the  posterior  wall  of  the  uterus  and  of  the 
ala  vespertilionis.  At  times  rudiments  only  could  be  observed  ;  in  other  cases 
numerous  strings  and  expansions  covered  the  whole  posterior  surface  of  the 
uterus  and  alse.  These  have  extended  over  the  anterior  aspect,  on  the  bladder 
or  rectum.  The  most  various  degrees  of  adhesion,  from  partial  attachment  to 
complete  capsular  investment  of  the  ovary,  were  found.  The  membranes  were 
thin,  delicate,  translucent,  and  could  be  easily  separated  from  the  serous  mem- 
brane, which  always  exhibited  its  normal  appearance.  Similar  appearances  are 
found  in  animals  whose  ovaries  lie  free,  as  in  man. — Brit,  and  For.  Med.-Chir. 
Review,  Oct.  1862,  from  St.  Peter sb.  Med.  Zeitschr.,  1862,  and  Mon.f.  Geburtsk, 
June,  1862. 

76.  Ovarian  Cyst  Discharging  through  Vagina. — The  following  note  from 
Dr.  Irvine,  of  Pitlochry,  was  communicated  to  the  Edinburgh  Obstetrical  So- 
ciety : — 

"  Mrs.  Sloan,  set.  42  ;  married  for  twenty-two  years.  Never  pregnant.  Has 
menstruated  regularly  all  her  life,  and  still  continues  to  do  so.  First  discovered 
a  swelling  in  her  right  side  fifteen  years  ago,  which  was  recognized  as  an  ovarian 
tumour.  For  six  years  the  abdomen  has  been  enormously  distended,  much  as  at 
present,  when  it  measures  46  inches,  she  being  a  middle-sized  and  spare  woman. 
She  suffered  much  from  the  distension,  such  as  inability  to  lie  down,  retention  of 
urine  requiring  the  aid  of  the  catheter,  cedematous  legs,  etc.,  until  a  year  ago, 
when  a  watery  fluid  began  to  escape  from  the  vagina,  and  has  continued,  almost 
weekly,  ever  since,  with  obvious  subsidence  on  each  occasion  of  the  abdominal 
distension  and  relief  of  her  distress.  The  quantity  discharged  at  any  time  she 
estimated  at  about  a  quart,  sometimes  more,  sometimes  less  ;  but  it  is  invariably 
most  abundant  just  before  the  menstrual  period ;  at  this  time  she  has  always 
experienced  an  increase  of  her  sufferings,  but  this  monthly  aggravation  has  been, 
much  less  since  the  watery  discharge  began.  The  fluid  escapes  without  previous 
warning  or  accompanying  pain,  often  when  sitting  quietly  in  her  chair,  is  per- 
fectly limpid,  and  scarcely  stiffens  or  discolours  her  linen.  Her  general  health 
is  good,  she  performs  the  work  of  her  house  often  without  a  servant,  can  walk 
several  miles  at  a  time,  and  her  chief  complaint  is  of  the  weight  and  of  the  ach- 
ing in  her  loins  after  any  fatigue." 

Dr.  Moir  mentioned  that  the  late  Dr.  Hamilton  had  a  similar  case,  the  pre- 
paration of  which  was  in  the  University.    He  (Dr.  M.)  thought  that  in  cases 


25G 


Progress  of  the  Medical  Sciences. 


[Jan. 


where  the  ovary  was  adhesive  to  the  Fallopian  tube,  that  the  fluid  might  find 
its  way  through  the  latter  into  the  uterus  and  vagina. 

Dr.  A.  Simpson  stated  that  Frank  had  recorded  a  case  of  this  kind,  and  had 
expressed  the  opinion  that  the  periodical  discharge  of  fluid  took  place  through 
the  Fallopian  tube  ;  but  it  was  difficult  to  conceive  of  that  narrow  canal  allow- 
ing of  the  passage  of  the  large  quantities  of  fluid  that  seemed  at  times  in  such 
cases  to  escape  ;  and  it  might  perhaps  be  found  that  in  some  of  these  cases  an 
adhesion  had  taken  place  between  the  cyst  and  the  body  of  the  uterus  or  the 
roof  of  the  vagina,  where  subsequently  rupture  of  the  walls  occurred. — Edin- 
burgh Med.  Journal,  Oct.  1862. 

77.  Diseased  Placenta. — Dr.  McClintock  observed,  at  the  meeting  of  the 
Dublin  Pathological  Society,  March  29,  1862,  that  diseases  of  the  after-birth 
were  so  rare,  and  their  pathology  was  so  much  involved  in  obscurity,  that  any 
new  fact,  however  small,  was  worth  being  brought  forward,  and  put  on  record. 
Before  he  showed  the  coloured  drawing  he  intended  exhibiting  to  the  society,  he 
would  advert  to  the  pathology  of  the  disease,  which  had  been  very  unnappily 
termed  "hydatids  of  the  uterus,"  which  was  a  great  misnomer — for  the  disease 
in  question  was  not  hydatids,  neither  was  the  uterus  the  part  affected.  The 
disease  was  seated  in  the  chorion,  and  consisted  in  a  development  of  cysts  on  its 
outer  surface.  It  was  correctly  called,  by  Mr.  Paget,  "  cystic  disease  of  the 
ovum." 

There  was  no  recorded  instance  of  a  living  embryo  being  born  of  a  mother 
who  had  this  cystic  disease.  The  opinion  entertained  in  the  present  day  was 
that  the  cystic  disease  in  the  chorion  was  a  consequence,  a  result  of  the  death 
of  the  embryo,  and  not  the  cause.  There  were,  just  then,  two  points  which 
he  wanted  to  dwell  upon  with  reference  to  hydatids  of  the  uterus  :  First,  That 
the  disease  occurred  in  the  villi  of  the  chorion.  Secondly,  that  it  was  extremely 
rare  to  see  an  embryo  expelled  when  the  disease  existed ;  and  that  there  was  no 
recorded  example  of  a  living  embryo  being  so  expelled.  Nine  cases  came  under 
his  own  care  of  the  disease,  and  in  one  only  was  there  any  vestige  of  an  embryo. 
These  cysts  very  rarely  became  developed  after  three  or  four  months  ;  but  when 
they  originated  after  that  period  they  were  necessarily  confined  to  the  placenta. 

Now  these  remarks  were  merely  prefatory  to  the  exhibition  of  this  very  beau- 
tifully executed  and  faithful  representation  of  a  placenta.  The  history  of  the 
case  was  as  follows :  The  patient  from  whom  this  placenta  was  expelled  was 
confined  in  the  Lying-in  Hospital,  at  the  end  of  eight  months,  of  twins.  There 
were  two  placentas,  of  about  the  usual  size,  one  of  which  was  represented  in  the 
drawing.  Both  children  were  alive  ;  and,  on  an  examination  of  the  surface  of  the 
after-birth,  there  were  discovered  four  or  five  well  marked  cysts,  the  largest  the 
size  of  a  full  grown  grape.  Now  what  was  the  nature  of  these  cysts  ?  He  was  not 
aware  of  any  recorded  instance  where  such  a  morbid  appearance  was  found  in  the 
placenta.  He  had  examined  many  diseased  placentas  himself,  and  except  in  that 
solitary  instance,  he  never  saw  anything  similar  to  this.  They  were  true  cysts, 
and  contained  a  limpid  yellowish-coloured  fluid,  of  a  somewhat  syrupy  consist- 
ence. On  close  examination  these  cysts — five  in  number — were  found  lying  on 
the  external  surface  of  the  chorion,  and  closely  connected  with  it.  Now,  what 
was  the  nature  of  these  cysts?  In  what  light  are  they  to  be  regarded  ?  He  was 
of  opinion  that  their  pathogenesis  was  the  same  as  that  of  the  cystic  disease  or 
vesicular  hydatid  of  the  ovum.  They  were  certainly  a  cyst  formation,  attached 
to  the  outer  surface  of  the  chorion.  If  this  opinion  were  correct,  the  case  was 
a  very  singular  one,  as  furnishing  an  example  of  the  Vesicular  hydatids  at  so  late 
a  period  of  gestation  as  the  eighth  month,  and  also  as  being  in  connection  with 
a  living  foetus. — March,  29, 1862. — Dublin  Quart.  Journ.  Med.  Sci.,  Aug.  1862. 

78.  Apnoea  Neonatorum. — Mr.  Greaves,  of  Manchester,  in  a  valuable  paper 
on  this  subject  in  the  British  Medical  Journal,  page  65,  thus  sums  up  the  con- 
clusions at  which  he  has  arrived  :  1.  That  the  effect  of  even  the  earlier  labour- 
pains  is  to  close  the  ultimate  ramifications  of  the  uterine  arteries,  but  that  this 
closure  is  temporary  only,  and  ends  with  the  termination  of  each  pain.  2.  That, 
during  the  pains,  the  blood  contained  in  the  sinuses  of  the  maternal  placenta, 


1863.] 


Medical  Jurisprudence  and  Toxicology. 


257 


not  being  renewed  by  fresh  supplies  of  arterial  blood  from  tlie  curling  arteries, 
cannot  effect  the  needful  changes  in  the  foetal  blood  in  the  placental  tufts.  3. 
That  the  blood  contained  in  the  tufts,  remaining  venous,  stagnates  in  their 
'capillaries,  and  that  the  umbilical  circulation  is  thus  arrested.  4.  That,  as  a 
consequence  of  this  arrest,  the  aorta  of  the  foetus  and  the  ventricles  of  its  heart 
become  congested,  and  at  the  same  time  the  brain  ceases  to  be  supplied  with 
arterialized  blood.  5.  That,  consequently,  the  rate  of  pulsation  of  the  foetal 
heart  sinks  nearly  to  half  its  normal  frequency.  6.  That,  if  these  periods  of 
lowered  force  of  the  foetal  circulation  occur  too  frequently,  as  in  tedious  labour, 
or  too  closely  together,  as  in  very  hurried  parturition,  the  child  may  be  born 
almost  or  altogether  inanimate.  7.  That  the  effects  of  the  suspension  of  the 
breathing  function  of  the  placenta  are  intensified  by  pressure  on  the  funis,  or  on 
the  head  or  thorax  of  the  foetus.  8.  Th.at  where  there  is  not  some  mechanical 
obstruction  to  respiration,  such  as  tenacious  mucus  in  the  fauces,  or  the  mem- 
branes over  the  face,  the  efficient  cause  of  still-birth  is  an  excessive  degree  of  a 
condition  which  at  birth  always  prevails  normally,  viz.,  congestion  of  the  fcetal 
heart,  which  is  to  be  relieved,  first  by  bleeding  from  the  cord,  and,  secondly,  by 
exciting  respiration.  9.  That  the  difference  between  the  syncopal  and  apoplec- 
tic forms  of  still-birth,  is  that  in  the  latter  there  have  been  imperfect  acts  of 
respiration  which,  by  closing  the  foramen  ovale,  have  caused  general  venous 
congestion. — Lond.  Med.  Rev.,  Oct.  1862. 


MEDICAL  JUKISPKUDENCE  AND  TOXICOLOGY. 

79.  New  Cause  of  Death  under  Chloroform. — Dr.  G-.  W.  Balfour  remarked 
at  the  meeting  of  the  Obstetrical  Society  of  Edinburgh,  June  12,  1861,  that  as 
the  public  and  the  profession  were  indebted  to  an  obstetric  physician  for  the 
benefits  of  chloroform,  the  following  peculiar  case  of  death  from  that  article, 
though  strictly  speaking  a  surgical  one,  could  not  be  uninteresting  to  an  obstet- 
rical society.  The  case  occurred  during  the  Burmese  war  in  1853;  and  was 
related  in  a  letter  from  John  Balfour,  Esq.,  D.I.  G.,  then  field-surgeon  to  the 
army  in  Burmah.  A  soldier  received  a  gunshot  wound  through  the  upper  part 
of  the  thigh,  and  secondary  hemorrhage  repeatedly  recurred.  It  was  supposed 
that  the  profunda  or  one  of  its  branches  was  injured,  and  it  was  determined  to 
tie  the  femoral  artery  above  and  below  the  origin  of  the  profunda; — this  was 
done  while  the  man  was  under  chloroform.  In  the  course  of  the  operation  the 
man,  who  had  had  his  dinner  previously,  became  sick  and  vomited.  He  subse- 
quently sank  and  shortly  died  from  exhaustion,  as  was  supposed.  On  examina- 
tion of  the  body,  the  profunda  was  found  cut  across  by  the  ball,  and  a  false 
aneurism  formed  at  the  seat  of  injury,  and  the  trachea  was  found  filled  with 
vomited  matters.  Dr.  Balfour  remarked  that,  though  an  extreme  case,  this  was 
but  a  sample  of  one  very  common  source  of  danger  in  the  use  of  chloroform, 
arising  from  its  anaesthetic  properties  interfering  with  the  natural  actions  of  the 
nervous  system,  and  that  the  anaemic  condition  of  the  patient  probably  had  its 
influence  in  favouring  the  fatal  result,  anaemia  being  one  of  the  conditions  most 
commonly  found  in  all  fatal  cases  following  the  using  of  chloroform ;  in  which, 
however,  by  far  the  most  common  and  constant  post-mortem  appearance  was  a 
collapsed  condition  of  the  heart,  a  condition  rarely,  if  ever,  found  after  death 
from  any  other  cause,  and  favouring  the  supposition  that  death  in  most  of  such 
cases  is  caused  by  direct  paralysis  of  that  organ,  a  supposition  further  favoured 
by  the  fact,  that  death  from  chloroform  has  generally  occurred  when  the  patients 
were  in  the  sitting  or  half-lying  posture,  when  of  course  syncope  was  more  likely 
to  occur  than  when  wholly  recumbent,  as  well  as  by  its  remarkable  safety  in 
midwifery,  in  which  we  had  a  most  efficient  and  delicate  test  of  its  action  on  the 
hollow  involuntary  muscles  in  its  action  on  the  uterine  pains.  Dr.  Balfour  also 
directed  attention  to  a  statement  of  Stanelli,  that  bubbles  of  gas  had  been  seen 
escaping  from  the  veins  and  arteries  of  those  operated  on  under  chloroform,  and 
to  the  possibility,  therefore,  of  chloroform  forming  gaseous  bubbles  within  the 
vascular  system,  interfering  with  the  heart's  action,  and  thus  proving  a  merely 
No.  LXXXIX.— Jan.  1863.  17 


258 


Progress  of  the  Medical  Sciences. 


mechanical  cause  of  death.  He  also  pointed  out  that  Dr.  Casper,  of  Berlin, 
had  distinctly  made  out  the  possibility  of  chronic  chloroform  poisoning1,  which 
might  end  fatally  after  hours,  days,  or  even  weeks ;  and  that  this,  though  a  sub* 
ject  of  extreme  difficulty,  was  one  which  deserved  most  careful  consideration,' 
particularly  in  regard  to  cases  of  death  after  childbirth,  in  which  chloroform  had 
been  employed,  and  where,  from  the  apparent  absence  of  any  sufficient  cause, 
the  death  had  usually  been  referred  to  toxaemia.  In  midwifery,  we  have  a  most 
efficient  test  of  the  saturation  of  the  patient's  system  with  chloroform  in  its 
action  on  the  uterine  pains,  and  as  its  interference  with  the  continuance  of  these 
is  a  signal  for  its  partial  withdrawal,  there  is,  we  may  almost  say,  a  positive 
immunity  from  sudden  death  from  chloroform  during  labour,  because  the  heart's 
action  continues  wholly  unaffected  long  after  anaesthetics  have  produced  com- 
plete cessation  of  the  labour  pains.  But  the  long  continuance  of  labour  gene- 
rally, and  the  amount  of  chloroform  administered  during  its  continuance,  is 
most  favourable  to  the  production  of  a  state  of  chronic  poisoning,  particularly 
where  the  patient  was  originally  anaemic,  or  has  become  so  by  flooding  subse- 
quent to  parturition;  and  in  the  latter  case,  the  loss  of  a  very  small  amount  of 
blood,  the  vital  stimulant,  might  very  readily  prove  fatal  where  the  heart  was 
already  half  paralyzed.  The  subject  seemed  to  be  one  deserving  of  the  most 
careful  consideration. 

Kemarks  were  made  by  various  members  as  to  the  inconvenience  and  occa- 
sional danger  of  administering  chloroform  to  patients  who  had  been  taking  food 
shortly  before ;  and  cases  in  point  were  adduced.  It  had  been  observed  also 
that  the  same  patient  required  a  larger  dose  of  chloroform  after  a  meal  than 
she  did  when  she  was  anaesthetized  fasting. — Ed.  Med.  Journal,  Aug.  1862. 

80.  Tannin  as  an  Antidote  to  Strychnia. — Prof.  Kurzak  gives  the  following 
results  of  experiments  made  by  him  upon  rabbits  and  dogs,  in  which  tannin  was 
administered  as  the  antidote  to  strychnia.  He  says  that  when  administered  in 
proper  time,  tannin  is  an  excellent  antidote,  and  the  favourable  results  produced 
by  the  experiments  on  rabbits  and  dogs  give  every  hope  of  analogous  results 
upon  man. 

It  is  necessary  that  the  dose  of  tannin  be  from  twenty  to  twenty-five  times 
that  of  the  strychnia  which  has  been  taken ;  and  in  cases  of  poisoning,  it  would 
even  be  prudent  to  make  the  dose  of  tannin  much  stronger  still. 

The  powder  can  be  immediately  employed  and  obtained  by  pulverizing  nut- 
galls,  and  then  making  an  infusion  of  this  latter  substance. 

An  infusion  of  black  tea  may  be  useful  when  the  dose  of  strychnia  is  not  very 
great;  coffee  also  possesses  the  same  properties,  but  in  a  less  degree  than  tea. 

The  bark  of  the  oak,  which  contains  8.5  in  100  of  tannic  acid,  may  be  ren- 
dered serviceable  by  the  facility  with  which  it  can  be  procured ;  it  is  also  em- 
ployed pulverized  or  in  decoctions  similar  to  that  of  nut-galls. 

The  author  mentions  besides,  acorns,  the  bark  of  the  chestnut-tree  and  the  wil- 
low, the  skins  of  nuts,  the  root  of  tormentil,  pinks,  and  snakeweed  as  rich  in  tannin. 

It  is  important  to  avoid  the  use  of  vegetable  acids  whilst  administering  tannin, 
on  account  of  the  solubility  in  these  acids  of  the  precipitate  produced  by  the 
tannin  in  the  solutions  of  strychnia.  It  is  the  same  with  alcoholic  drinks.  In 
fact,  it  is  important  to  avoid  every  kind  of  voluntary  movement,  and  all  excite- 
ment, of  whatever  nature  it.  may  be,  these  influences  being  capable  of  producing 
spasmodic  contractions. — B.  and  F.  Med-Clxir.  Rev.,  Oct.  1862,  from  Zeitschrift 
der  Jc.  Tc.  Gesellschaft  der  Aerzte  zu  Wein,  1862. 

81.  Detection  of  Blood  Stains.  By  Dr.  Erdmann. — The  most  recent  investi- 
gations have  shown  that  the  crystals  of  haemine  discovered  by  Erdmann  are  the 
only  constant  elements  of  a  solid  judgment  as  to  the  nature  of  stains  of  a  doubt- 
ful nature.  There  is  no  question  but  that  blood-globules  are  characteristic  of 
blood  ;  but  as  in  many  cases  the  stains  to  be  submitted  to  analysis  are  not  recent, 
and  as  the  red  globules  become  altered  with  great  facility,  their  presence  cannot 
serve  as  an  infallible  criterion.  As  to  the  white  corpuscles,  Neuhauer  has  put 
in  its  true  light  the  importance  which  has  been  recently  attempted  to  be  attached 
to  them,  by  reminding  microscopists  that  precisely  similar  bodies  exist  in  urine, 
saliva,  mucus,  and  it  m  ay  be  added  in  pus.    On  the  other  hand,  a  chemical  ex- 


1863.] 


Medical  Jurisprudence  and  Toxicology. 


259 


animation  cannot  lead  to  a  satisfactory  result,  because  all  the  chief  principles 
of  blood  are  met  with  in  other  animal  fluids,  and  in  addition  several  vegetable 
albumenized  matters  present  the  same  reaction  as  the  albuminous  elements  of 
'the  blood. 

Erdmann  records  a  recent  case  which  shows  at  once  the  insufficiency  of  a 
chemical  examination,  and  the  necessity  which  exists  for  an  extreme  reserve  in 
all  medico-legal  microscopic  researches.  The  only  trace  of  an  assassination 
committed  at  Leipsic  was  a  brownish  stain  situated  un  the  spot  where  the  crime 
had  been  perpetrated ;  under  the  influence  of  rain  this  stain  had  assumed  the 
appearance  of  coagulated  blood.  An  aqueous  solution  of  this  stain  furnished  a 
reddish  fluid,  which  gave,  with  tannin,  with  ferrocyanide  of  potassium,  and  with 
Millon's  solution,  the  same  chemical  reaction  as  the  aqueous  extract  of  dried 
blood.  Examined  under  the  microscope,  the  brown  matter  was  found  to  contain 
some  corpuscles  similar  to  those  of  blood.  But  Erdmann  having  failed  to  dis- 
cover crystals  of  hasmine,  conceived  doubts  as  to  the  value  of  the  other  charac- 
ters, and  repeated  with  greater  care  the  microscopical  examination ;  he  then 
discovered  that  the  bodies  supposed  to  be  blood-globules  were  the  spores  of  an 
alga,  which  has  been  called  the  Porphyridium  cruentum  precisely  on  account 
of  the  resemblances  of  its  spores  to  the  globules  of  the  blood. 

Erdmann  in  the  course  of  his  subsequent  researches  has  simplified  the  method 
of  Brticke  for  obtaining  crystals  of  hseniine,  and  has  reduced  it  to  the  following 
steps  :  He  macerates  the  suspected  stain  in  water  and  slowly  evaporates  the 
solution ;  he  places  this  aqueous  extract  on  one  of  the  slips  of  glass  used  in 
microscopic  examinations,  and  adds  to  it  a  minute  crystal  of  common  salt  and 
a  drop  of  glacial  acetic  acid ;  he  exposes  the  slip  of  glass  to  a  gentle  heat  over 
a  spirit-lamp  and  evaporates  to  dryness ;  when  the  glass  is  cool  he  adds  a  drop 
of  acetic  acid,  and  places  the  whole  under  a  microscope  with  a  magnifying 
power  of  250  diameters.  If  the  stain  contained  blood,  crystals  of  haemine  will 
infallibly  be  seen  in  the  drop  of  acetic  acid;  these  are  rhomboidal  plates  arranged 
in  groups  around  a  central  point ;  their  colour  varies  according  to  their  thick- 
ness from  yellow  to  red  ;  the  special  character  of  these  crystals  is  their  solubility 
in  caustic  potash.  Erdmann  maintains  that  by  this  method  he  has  obtained 
crystals  of  haamine  from  a  stain  of  blood  which  could  not  be  seen  without  a 
magnifying-glass. — Gazette  Hebdom.  from  Zeitsch.fur  Analyt.  Chemie.,11. 1862. 

82.  The  Hcemine  Crystals  in  different  Animals. — Dr.  Wilbrand  has  endea- 
voured to  determine  whether  haemine  crystals  from  the  blood  of  different  species 
of  animals  can  be  distinguished  by  any  crystallographic  peculiarities.  The  fol- 
lowing are  the  characteristic  differences  so  far  as  they  have  yet  been  deter- 
mined:— 

The  crystals  from  human  blood  are  lamellar-prismatic;  that  is  to  say,  the 
crystals  are, thin,  but  relatively  broad,  the  length  being  only  from  one  and  a  half 
to  three  times  the  breadth.  The  crystals  from  the  blood  of  the  ox  and  the  mouse 
are  elongated-prismatic,  being  from  six  to  ten  times  as  long  as  broad.  The 
blood  of  the  ox  and  the  mouse  may,  however,  be  distinguished  from  one  another 
by  the  arrangement  of  the  crystals.  The  first  forms  the  model  of  a  hexagonal 
axis-cross  or  parts  of  it ;  the  latter  of  a  monoklinometric  cross  or  parts  thereof. 
Accordingly,  in  the  blood  of  the  ox  we  find  six-rayed  stars  formed  from  three 
crystals  which  intersect  one  another  in  a  plane  under  sixty  degrees.  Such  stars 
are  not  found  in  the  blood  of  the  mouse  ;  but  two  torms  of  cross  found  in  it  are 
specific — rectangular  crosses  formed  from  two  crystals  which  present  their  nar- 
row margins ;  and  oblique  crosses,  the  acute  angles  of  which  amount  to  rather 
more  than  two-thirds  of  a  right  angle.  In  addition  to  these  kinds  of  blood, 
Wilbrand  experimented  on  that  of  the  sheep  and  the  pig,  but  failed  to  find 
characteristic  differences.  The  characters  of  the  haemine  crystals  from  the  blood 
of  man,  the  ox,  and  the  mouse,  serve  merely  to  distinguish  them  from  those  from 
the  sheep  and  the  pig. — Ed.  Med.  Joum.,  Oct.  1862,  from  Vierteljahrschrift 
filr  die  praktische  Heilkunde. 

83.  Poisoning  by  Nitrate  of  Strychnia,  Acetate  of  Morphia,  Bitter-Almond 
Water,  and  Chloroform.  By  Dr.  Tschepke. — On  the  26th  of  November,  a  little 
before  eleven  in  the  evening,  Dr.  Tschepke  was  summoned  to  see  E.,  a  druggist's 


2G0 


Progress  of  the  Medical  Sciences. 


assistant, -who  had  voluntarily  poisoned  himself.  He  was  found  in  bed,  pale, 
the  eyes  closed,  stiff  as  a  corpse.  One  of  those  present  showed  a  phial  contain- 
ing nitrate  of  strychnia,  which  the  young  man  had  employed.  Dr.  Tschepke 
took  hold  of  the  hand  in  order  to  feel  the  pulse ;  immediately  on  this  simple 
contact  the  body  was  affected  as  if  by  an  electric  shock ;  the  pulse  became 
scarcely  perceptible  ;  the  respiration  was  suspended.  At  the  end  of  a  few 
minutes  the  patient  opened  his  eyes,  and,  in  reply  to  a  question,  stated  that  he 
had  taken  strychnia.  Whilst  an  emetic,  consisting  of  antimony  and  ipecacu- 
anha, was  being  prepared,  spontaneous  vomiting  occurred  of  a  reddish  matter, 
having  the  smell  of  bitter  almonds.  The  emetic  was  administered,  and  a  solution 
containing  three  grains  of  tannin  in  each  dose  was  prescribed.  The  emetic  pro- 
duced two  copious  discharges,  after  which  E.  scratched  his  face  and  body  vio- 
lently, and  tore  his  hair ;  then  supervened  starting,  clonic  convulsions,  tetanic 
rigidity,  opisthotonos,  and  suspension  of  the  pulse  and  of  the  respiration. 
Touching  the  arm  produced,  at  first,  a  fresh  attack.  The  tannic  acid  and  the 
emetic  were  given  every  alternate  quarter  of  an  hour.  Yomiting  and  cramps 
succeeded  one  another ;  the  same  train  of  symptoms  recurred.  At  the  end  of 
an  hour  the  patient  was  able  to  speak,  and  stated  that  he  had  first  taken  strych- 
nia, then  acetate  of  morphia,  each  of  these  substances  in  an  ounce  of  bitter- 
almond  water,  and  that  he  had  poured  on  his  pillow  a  certain  quantity  of  chlo- 
roform. 

Half  an  hour  after  midnight  the  use  of  the  emetic  was  discontinued,  and  three 
grains  of  tannic  acid,  with  a  quarter  of  a  grain  of  codeine,  were  given  every  half 
hour.  Occasional  vomiting  and  cramps  recurred  until  four  o'clock  in  the  morn- 
ing. There  was  still  great  anxiety,  feebleness,  and  dryness  of  the  throat ;  the 
respiration  was  short  and  hurried.  To  allay  his  thirst,  he  was  ordered  milk  of 
almonds,  milk,  tea,  and  finally  seltzer  water.    Urination  was  painful. 

In  the  morning  the  patient  was  sufficiently  recovered  to  narrate  what  had 
taken  place.  At  half-past  eight  o'clock  he  had  taken  between  eight  and  ten 
grains  of  the  nitrate  of  strychnia  in  an  ounce  of  bitter-almond  water.  A  little 
later  he  swallowed  an  additional  dose  of  twelve  grains  of  strychnia.  Feeling 
nothing  particular,  he  took  at  nine  o'clock  ten  grains  of  acetate  of  morphia  dis- 
solved in  an  ounce  of  bitter-almond  water,  and  then  lay  down  in  bed.  Ten 
minutes  later  he  recollected  that  he  had  some  chloroform  ;  he  poured  some  of  it 
on  his  pillow  to  hasten  his  death.  It  appears  that  he  was  insensible  for  an  in- 
stant, and  then  felt  in  the  nose  and  the  limbs  an  intolerable  itching.  Feeling 
no  effect  from  the  poison,  he  wished  to  get  up  to  look  at  his  watch,  but  was 
unable  to  do  so.  He  remained  in  a  state  of  partial  insensibility  till  the  arrival 
of  a  fellow-assistant  at  about  a  quarter  to  eleven.  He  heard  him  enter ;  and  as  the 
latter  was  leaving  the  room  to  get  assistance,  he  was  seized  with  violent  cramp, 
with  cessation  of  the  respiration,  but  without  pain.  He  then  lost  consciousness, 
but  only  for  a  short  time ;  and  when  he  came  to  himself,  had  another  attack  of 
convulsions.  At  this  moment  the  physician  entered,  and  made  the  observations 
already  noted.    Two  days  afterwards  no  trace  of  the  poisoning  remained. 

The  various  symptoms  in  this  remarkable  case  may  be  referred  to  the  differ- 
ent poisons.  To  the  strychnia  must  be  referred  the  cramps,  the  violent  move- 
ments of  the  body  on  the  slightest  touch,  and  the  phenomena  of  asphyxia.  To 
the  morphia  belongs  the  itching  of  the  nose,  of  the  limbs,  and,  later,  of  the  whole 
body.  The  bitter-almond  water  and  the  chloroform  appear  to  have  produced  no 
special  effect. 

We  may  well  be  surprised  that  such  large  doses  of  strychnia  did  not  cause 
death ;  but  this  is  to  be  accounted  for  by  the  following  circumstances :  The 
young  man,  before  poisoning  himself,  had  partaken  freely  of  a  sort  of  soup  made 
with  flour  and  a  species  of  cranberries.  These  latter  contain  tannin,  an  agent 
which  neutralizes  strychnia ;  and  the  farinaceous  matters,  by  enveloping  the 
poison,  had  prevented  its  absorption. 

On  the  other  hand,  opium  has  been  found  to  be  an  antidote  to  strychnia;  so 
that  the  mixture  of  poisons  which  the  poor  creature  had  taken  to  hasten  his 
death  had  had  precisely  the  opposite  effect.  It  is  right  to  add  that  the  emetics, 
continued  without  interruption  during  several  hours,  no  doubt  had  a  considerable 
effect  in  bringing  about  this  fortunate  result. — Ed.  Med.  Journ.,  Oct.  1862,  from 
Gaz.  M6d.  de  Paris  and  Deutsche  Klinik. 


1863.] 


Medical  Jurisprudence  and  Toxicology. 


261 


84.  Poisoning  by  Sulphuric  Acid.  By  Antonio  Cozzi. — This  interesting 
monograph  is  founded  upon  the  study  of  twelve  cases  of  poisoning  by  sulphuric 
acid  observed  by  the  author  at  the  Hospital  of  Santa-Maria-Nuova,  at  Florence, 
between  the  month  of  February,  1852,  and  January,  1861.  With  one  exception, 
all  the  poisonings  were  the  result  of  attempts  at  suicide.  The  analysis  of  these 
observations  has  led  Cozzi  to  the  following  conclusions  regarding  the  objective 
and  subjective  symptoms  which  follow  the  ingestion  of  the  poison: — 

1.  The  fluids  discharged  by  vomiting  are  generally  as  black  as  ink ;  in  some 
cases  they  have  been  sauguinolent. 

2.  It  sometimes  happens  that  the  phenomena  of  spasm  and  irritation,  deter- 
mined by  the  caustic  substance,  predominate  at  first  in  the  situation  of  the 
pharynx,  and  that  epigastric  pain  only  comes  on  later ;  under  these  circum- 
stances death  occurs  suddenly,  before  anything  causes  the  physician  to  suspect 
its  imminence. 

3.  Entering  the  larynx  and  bronchi,  the  sulphuric  acid  may  develop  a  fatal 
inflammation,  and  determine  grave  disorders  in  the  organ  of  voice.  The  pene- 
tration of  the  acid  into  the  air-passages  is  due  to  the  instantaneous  impression 
which  it  produces  upon  the  tongue ;  the  spasmodic  contraction  of  the  pharynx 
prevents  deglutition,  at  the  same  moment  an  access  of  cough  occurs,  and  in  the 
succeeding  inspirations  the  liquid  falls  into  the  trachea  and  bronchi,  and  may 
even  enter  the  lung. 

4.  When  the  degree  of  concentration  and  the  dose  of  acid  swallowed  are  suf- 
ficient, an  immediate  perforation  of  the  stomach  may  take  place ;  in  this  vomit- 
ing and  diarrhoea  are  absent.  In  this  case  also  the  swallowing  of  liquids 
increases  the  pain ;  the  pulse  becomes  thready,  the  prostration  is  complete,  the 
limbs  are  covered  with  a  cold  sweat,  and  death  occurs  in  a  few  hours,  the  patient 
retaining  consciousness  to  the  last. 

5.  If  the  acid  is  weak  and  much  diluted,  the  general  symptoms  are  at  first  less 
severe,  the  local  accidents  predominate,  but  may  themselves  present  a  slight 
remission ;  but  an  inflammatory  reaction  soon  sets  in  which  carries  off  the 
patient.  In  other  cases,  nervous  symptoms  and  grave  disorders  of  the  assimila- 
tion manifest  themselves ;  the  patient  cannot  regain  strength,  and  after  prolonged 
suffering  he  expires,  either  from  a  chronic  gastro-enteritis,  from  ulceration  of 
the  stomach,  or  from  stricture  of  the  oesophagus  or  of  some  other  part  of  the 
digestive  tube. 

6.  Sulphate  of  indigo  probably  possesses  toxic  properties  as  intense  as  those 
of  pure  sulphuric  acid. —  Gazette  Hebdomadaire  from  La  Sperimentale. 

85.  Poisoning  by  Bitter  Almonds,  with  Iodide  of  Iron. — M.  Toscani  admin- 
istered, as  a  tonic,  the  syrup  of  iodide  of  iron  to  a  child  about  six  years  old, 
with  great  success.  While  under  this  treatment,  in  opposition  to  repeated 
warnings,  a  person  gave  to  this  child  two  bon-bons  containing  essence  of  bitter 
almonds.  One  hour  afterwards  the  mother  gave  a  teaspoonful  of  the  syrup  of  the 
iodide.  At  the  end  of  another  hour,  intense  cardialgia  and  faintness  succeeded 
each  other  at  short  intervals  for  three  hours.  In  a  moment  of  rest  a  little  soup 
was  given  which  brought  on  vomiting,  with  relief.  Recovery  took  place  in  five 
hours.  The  writer  of  the  above  case  remarks,  that  all  preparations  containing 
hydrocyanic  acid  should  be  taken  with  great  care  whenever  salts  of  iron  or 
mercury  are  being  administered,  as  they  form  with  these  poisonous  compounds 
of  extreme  activity.  Hence,  mixtures  containing  calomel  and  bitter  almonds 
are  peculiarly  dangerous. — B.  and  F.  Med.-Chir.  Rev.,  Oct.  1862,  from  Bullet, 
delle  Sci.  Med.  di  Bologna,  March,  1862. 

86.  Case  of  Rape  during  Sleep. — The  following  case,  tried  at  Dumfries  Court, 
on  the  26th  Sept.,  1862,  before  the  Hon.  Lords  Cowan  and  Neaves,  throws  light 
upon  a  vexed  question  of  medical  jurisprudence,  whether  it  be  possible  to  com- 
mit rape  upon  a  woman  while  asleep  ? 

The  prisoner,  William  M'Ewan  or  Palmer,  was  placed  at  the  bar  charged 
with  the  crime  of  wickedly  and  feloniously  having  carnal  knowledge  of  a  woman 
when  asleep,  and  without  her  consent,  by  a  man  not  her  husband. 

The  prisoner  plead  not  guilty. 


262 


Progress  of  the  Medical  Sciences. 


[Jan. 


The  following  is  the  material  part  of  the  evidence  : — 

Mrs.  M.  I  have  been  married  sixteen  years,  and  have  three  of  a  family.  My 
husband  keeps  a  hotel,  of  which  he  is  also  proprietor.  My  husband  and  I,  and 
two  of  our  children,  sleep  in  a  private  room  communicating  by  one  door  with  the 
kitchen,  and  by  another  with  the  bar.  One  of  the  children  sleeps  in  my  own 
bed,  and  the  other  in  a  small  folding-down  bed.  This  small  bed  is  near  the  fire- 
place, where  there  is  a  gas  bracket.  The  prisoner  has  been  eight  or  nine  years 
in  our  service  as  horsekeeper  and  ostler — he  did  not  sleep  in  the  house,  but  slept 
out. 

On  the  night  of  2d  May  last,  a  policeman  drove  to  the  door  with  a  prisoner 
about  half  past  ten  or  eleven  o'clock.  I  was  told  that  he  had  gone  to  the  prison 
with  the  prisoner  and  was  coming  back.  The  servants  were  all  to  bed  ;  they 
sleep  up  stairs.  It  was  arranged  that  I  was  to  wait  up  for  the  constable.  I 
went  into  my  own  room,  and  lay  down  upon  the  little  bed  near  the  fireplace.  I 
had  been  up  all  night  on  the  previous  night,  and  had  been  much  fatigued  during 
the  week  before.  My  husband  was  at  this  time  sitting  at  the  fire  reading  the 
papers.  He  was, to  go  to  bed  after  he  was  done  with  the  papers.  I  fell  asleep, 
and  was  very  sound  asleep.  I  lay  down  with  all  my  clothes  on.  I  was  dressed 
much  the  same  as  usual ;  lay  down  on  my  left  side.  The  door  was  on  my  right. 
The  little  bed  was  at  the  other  end  of  the  room  from  the  door  into  the  kitchen. 
I  felt  the  pressure  of  a  man,  and  thinking  it  was  my  husband,  I  raised  myself 
up.  It  was  that  blackguard — I  mean  the  prisoner.  He  was  lying  upon  me,  and 
when  I  rose  up  he  drew  himself  away.  My  clothes  I  found  folded  up,  and  the 
lower  part  of  my  person  was  exposed.  It  was  his  weight  that  awoke  me.  He 
withdrew  himself  when  I  awoke.  I  was  then  lying  more  upon  my  back.  When 
I  awoke,  his  body  was  in  contact  "with  my  person.  His  private  member  was  in 
my  private  parts.  I  felt  him  withdraw  it  from  them.  In  doing  so,  I  felt  a  dis- 
charge from  him  in  my  person,  and  all  about  on  my  clothes.  The  gas  was  at 
this  time  very  low ;  when  I  lay  down  it  was  high.  There  was  a  complete  mess 
on  my  clothes.  I  immediately  called  out  for  him  to  go  away  for  a  dirty,  filthy, 
blackguard.  As  he  went  away,  he  was  buttoning  up  the  front  part  of  his  trou- 
sers. The  prisoner  said  as  he  went  away,  to  say  nothing  about  it;  the  police- 
man is  waiting  for  his  money — to  cash  this  account  for  him.  The  police  often, 
when  they  came  late  at  night,  got  payment  from  me  of  their  accounts,  and  I  got 
payment  afterwards  from  the  authorities.  I  rose  to  my  feet  in  a  moment ; 
prisoner  went  sideways  towards  the  kitchen.  My  husband  awoke.  I  still  cried 
out  to  prisoner  to  go  away.  I  told  my  husband  about  prisoner.  He  got  up  and 
had  him  taken  away.  I  was  greatly  agitated.  Husband  got  the  constable  to 
take  prisoner  in  charge.  The  prisoner  said,  I've  done  it,  and  I'm  sorry  for  it — 
he  was  then  in  the  kitchen.  My  husband  went  with  the  constable  to  take  prisoner 
to  prison.  When  he  came  back  I  told  him  everything.  This  was  a  little  after 
twelve  o'clock,  about  a  half  or  three-quarters  of  an  hour  after  the  prisoner  did 
it,  There  was  light  enough  to  let  me  see  prisoner.  There  is  no  doubt  as  to  the 
man.  The  prisoner  never  before  came  into  my  room  without  knocking.  I  was 
on  no  terms  of  intimacy  or  particular  acquaintance  with  him.  The  prisoner  was 
rough  and  coarse  in  his  language,  but  a  good  enough  servant  otherwise.  He 
did  all  this  without  encouragement  from  me  at  any  time,  and  entirely  without 
my  consent.  When  I  went  into  my  room  to  lie  down,  the  prisoner  was  in  the 
kitchen.  I  suffered  from  the  effects  of  this  for  a  long  time.  I  was  much  dis- 
tressed, and  have  been  kept  from  sleeping  by  it.  I  might  have  slept  for  half  or 
three-quarters  of  an  hour  before  it  was  done.  When  I  lay  down,  my  dress  was 
quite  in  its  proper  state. 

The  husband's  testimony  corroborated  his  wife's,  and  he  stated  that  he  was 
quite  sure  his  wife  was  sound  asleep  when  he  went  to  bed. 

In  his  declaration,  the  prisoner  admitted  having  gone  into  the  room,  and 
having  raised  M  rs.  M.'s  petticoats,  and  placed  his  hand  upon  her  person,  but 
denied  anything  further. 

The  jury  unanimously  found  the  prisoner  guilty  as  libelled,  and  he  received 
sentence  of  ten  years'  penal  servitude. — Condensed  from  Edinburgh  Med.  Journ., 
Dec.  1862. 


1863.] 


263 


AMERICAN  INTELLIGENCE. 

ORIGINAL  COMMUNICATIONS. 

Abdominal  Carcinoma  resulting  in  Artificial  Anus  in  the  Upper  Third 
of  the  Ileum.  By  D.  Leasure,  M.  D.,  of  New  Castle,  Pa.— -On  the  18th 
of  December,  1857,  I  was  called  to  I.  W.,  bricklayer,  aged  43.  He  in- 
formed me  that  his  health  had  been  declining  for  three  or  four  years  ;  that 
during  a  sojourn  at  the  mines  in  California,  six  years  ago,  he  was  greatly 
exposed  to  vicissitudes  of  weather,  with  little  or  no  protection,  and  that  a 
violent  sickness  ensued,  from  which  he  never  entirely  recovered.  Since  his 
return,  four  years  since,  he  has  been  troubled  with  obscure  dull  pains  in 
his  abdomen,  with  a  sense  of  weight  and  dragging  in  his  back,  which  have 
gone  on  increasing  in  intensity,  and  within  the  last  year  sharp  lancinating 
pains  have  been  added  to  his  sufferings,  but  there  has  been  no  diminution 
of  the  dull  dragging  pain,  which  he  describes  "as  rather  a  sense  of  suffer- 
ing from  some  internal  weight  producing  inward  weariness,  than  a  real 
pain."  His  bowels  have  been  obstinately  costive,  though  cathartics  would 
always  give  temporary  relief,  to  be  followed  with  the  same  state  of  consti- 
pation as  soon  as  they  ceased  to  operate.  His  appetite  is  not  good,  though 
he  eats  with  a  sufficient  relish,  and  there  is  no  disposition  to  intolerance  of 
food,  nor  any  nausea.  His  kidneys  are  not  very  active,  and  there  is  a  good 
deal  of  sediment  in  the  urine,  which,  on  examination  under  the  microscope, 
proves  to  consist  largely  of  the  triple  phosphate  of  lime,  and  the  phosphate 
of  ammonia,  with  a  debris  of  broken  blood  globules  and  disorganized  tissues, 
the  precise  character  of  which  I  am  not  able  to  determine,  though  from  the 
presence  of  imperfect  sections  of  tubes  I  infer  that  it  is  probably  from  a 
kidney,  at  least  in  part.  He  informed  me  that  some  ten  months  since  he 
observed  that  there  was  a  tumour  in  his  left  side,  which  has  rapidly  increased 
in  size.  On  examination,  I  found  a  tumour  distinctly  lobulated  and  very 
firm,  occupying  about  one-third  of  the  left  sides  of  the  umbilical  and  hypo- 
gastric, and  nearly  all  of  the  left  lumbar  and  iliac  regions.  The.  tumour 
seemed  to  have  its  greatest  prominence,  about  the  intersecting  point  of  the 
dividing  lines  of  these  regions,  where  it  was  very  prominent  and  quite  hard, 
as  if  one  of  the  lobes  had  been  thrust  forward  at  that  point.  There  was 
no  tenderness  on  pressure,  and  the  tumour  seemed  to  be  firmly  attached,  so 
as  to  admit  of  but  little  motion.  The  general  appearance  of  the  patient 
was  that  of  a  man  labouring  under  a  general  cachexia,  but  with  no  distinct 
well  marked  characteristics  to  determine  precisely  the  nature  of  the  primary 
mischief.  Was  this  merely  a  case  of  general  mesenteric  disease,  with  great 
enlargement  of  the  mesenteric  glands,  attended  possibly  by  impacted  colon, 
or  was  it  carcinoma?  I  gave  the  patient  the  benefit  of  the  more  favourable 
diagnosis,  and  completely  evacuated  the  canal  by  free  laxatives,  and  very 
copious  enemata,  with  the  effect  of  bringing  away  about  half  a  gallon  of 
hardened  and  apparently  old  scybalas.  The  tumour,  however,  was  but  little 
diminished  in  size,  and  its  outlines  could  be  more  distinctly  made  oat.  I 
put  him  on  the  use  of  an  iodo-ferruginous  medication  with  no  benefit  at  all, 
and  the  case  seeming  to  progress  rapidly,  with  an  evident  tendency  on  the 
part  of  the  tumour  to  point,  as  though  pushing  its  way  to  the  surface,  I 
abandoned  all  treatment,  and  left  the  case  to  nature  for  some  weeks. 


264 


American  Intelligence. 


[Jan. 


About  the  first  of  February  succeeding,  the  lancinating  pains  became 
insupportable,  especially  at  night,  and  I  was  obliged  to  put  him  on  the 
use  of  opiates,  which  were  finally  pushed  to  the  extent  of  an  ounce  of 
McMunn's  elixir  per  diem.  The  tumour  still  pressed  towards  the  surface, 
the  skin  over  it  became  inflamed,  and  on  the  26th  of  February,  finding  that 
there  was  distinct  fluctuation,  and  an  evident  disposition  on  the  part  of  the 
skin  to  form  a  large  slough,  I  passed  a  small  trocar  obliquely  into  the  soft 
portion  of  the  tumour,  so  as  to  merely  pass  through  the  skin  and  cellular 
tissue  into  the  cavity  of  the  abscess,  without  penetrating  to  the  interior  of 
the  abdomen.  On  withdrawing  the  trocar,  about  four  tablespoonfuls  of 
pus,  and  a  strong  jet  of  gas  escaped  through  the  canula.  The  canula  was 
withdrawn,  and  a  bread  and  water  poultice  laid  over  the  part,  and  the 
puncture  closed  over  in  two  days  without  any  further  discharge. 

I  examined  the  pus  under  the  microscope,  as  did  also,  at  my  request,  Dr. 
S.  M.  Hamilton,  but  we  detected  nothing  that  might  not  have  been  found 
in  an  ordinary  abscess.  On  the  10th  of  March  the  tumour  again  pointed, 
and  on  the  12th  it  opened  spontaneously  at  the  seat  of  the  old  puncture, 
and  after  discharging  pus  for  three  or  four  clays,  the  contents  of  the  bowel 
passed  through,  and  as  substances  eaten  only  a  short  time  before  passed  out 
at  the  opening  undigested,  we  had  the  unpalatable  truth  forced  upon  us, 
that  we  had  to  deal  with  an  artificial  anus  high  up  in  the  ilium.  From 
this  period,  he  had  no  discharge  at  all  from  the  anus  proper,  or  lower  bowel, 
until  at  the  end  of  the  fifth  week  he  had  a  small  discharge,  of  which  he 
partially  relieved  himself  with  his  fingers,  but  on  throwing  up  a  syringe  full 
of  warm  soap  suds,  the  bowel  was  emptied  without  much  trouble,  and  then, 
about  every  third  or  fourth  day  there  would  be  a  similar  discharge,  but  it 
appeared  to  consist  almost  entirely,  if  not  altogether,  of  the  secretions  of 
the  bowel  itself.  From  this  time,  also,  till  the  30th  of  April,  the  patient 
lingered  in  great  suffering,  though  the  tumour  did  not  seem  to  develope 
itself  anteriorly,  and  on  that  day  I  again  punctured  the  integuments  low 
down  in  the  left  iliac  region,  over  a  large  sac  of  pus,  where  it  was  evident 
a  slough  was  about  to  separate  unless  I  did,  and  after  the  discharge  of 
about  half  a  pint  of  pus  the  contents  of  the  bowel  were  forcibly  ejected,  and 
another  artificial  anus  was  established.  At  this  time  he  was  extremely 
emaciated  and  harassed  with  violent  paroxysms  of  coughing.  Circulation 
and  innervation  have  been  but  little  disturbed  up  to  this  time,  but  now  he 
was  evidently  sinking,  and  the  pulse  run  up  to  about  one  hundred.  His 
intellection  was  not  disturbed  even  by  his  large  opiates  up  to  within  a  few 
hours  of  his  death,  which  took  place  on  the  4th  of  May. 

Autopsy  eighteen  hours  after  death  in  the  presence  of  Drs.  Cossit,  Cow- 
den,  White,  and  Peebles.  On  making  the  necessary  incisions,  and  deflecting 
the  skin  over  the  left  iliac  region,  a  large  cavity  was  exposed  partly  filled 
with  pus,  and  the  debris  of  broken-down  cellular  tissue.  Two  small  aper- 
tures opened  from  this  into  the  intestine,  through  which  the  contents  of  the 
bowel  escaped,  on  pressure  of  the  abdomen.  I  now  undertook  to  separate 
the  abdominal  fascia  from  the  muscles,  but  found  it  almost  impossible;  for 
so  completely  were  the  parts  blended  in  one  common  mass,  as  to  form  an 
apparently  new  tissue,  as  into  this  mass  the  peritoneum  had  also  been 
forced  to  enter,  and  I  was  obliged  to  deflect  all  the  abdominal  coverings 
together,  in  which  I  could  only  succeed  with  much  difficulty,  for  the  convo- 
lutions of  the  intestines  were  firmly  agglutinated  to  each  other,  and  also 
to  the  peritoneum,  and  it  was  in  these  extensive  adhesions  that  the  two 
apertures  existed  communicating  between  the  inner  surface  of  the  bowel  and 
the  surface  of  the  skin  constituting  the  artificial  ani.    Having  entirely  ex- 


1863.] 


Original  Communications. 


265 


posed  the  cavity  of  the  abdomen,  it  was  found  to  contain  several  pints  of 
a  light  coloured  whey  like  fluid :  and  a  large  and  firm  tumour  occupying 
the  entire  left  side  of  the  abdomen  in  its  whole  length,  and  including  in 
itself  the  duodenum,  jejunum,  and  about  one-third  of  the  ileum,  with  the 
transverse  and  descending  arches  of  the  colon,  and  their  attached  mesentery. 
The  substance  of  the  tumour,  aside  from  the  natural  parts  contained  in  it, 
was  an  immense  lobulated  scirrhus.  On  carefully  dissecting  the  tumour,  it 
was  found  that  while  the  scirrhus  enveloped  completely  the  portions  of  the 
bowel  passing  through  its  substance,  it  did  not  diminish  or  sensibly  encroach 
upon  the  natural  dimensions  or  calibre  of  the  gut,  but  so  encased  it,  as  to 
render  any  considerable  amount  of  peristaltic  motion  next  to  impossible; 
this  portion  of  the  intestine  was  quite  full  of  the  ordinary  half  digested 
ingesta  above  the  artificial  anus,  and  below  it  contained  only  the  products 
of  elimination  and  some  gas.  The  lower  two-thirds  of  the  ileum,  the  caput 
caecum,  and  ascending  arch  of  the  colon  were  not  in  any  way  implicated. 

The  substance  of  the  tumour  presented  carcinoma  in  all  its  stages  of 
scirrhus  and  cephaloma.  The  scirrhous  portions  varied  from  a  series  of  light 
straw-coloured  tumours,  of.  various  sizes,  to  the  firm,  hard,  gray,  and  gristly 
tumours  as  large  as  goose  eggs.  Many  parts  of  the  encephaloid  portions 
presented  the  appearance  of  broken-down  and  crumbled  cheese,  and  these 
seemed  to  be  enlarged  mesenteric  glands,  and  formed  the  principal  distinct 
lobes  of  the  tumour.  On  examining  carefully  the  seat  of  the  openings  in 
the  ileum,  I  found  that  one  of  these  lobes  had  softened,  and  taken  on  ulcera- 
tive action,  which  extended  itself  in  all  directions  equally,  and  a  convolu- 
tion of  the  ileum  being  in  its  way,  it  was  opened  on  its  anterior  surface, 
and  the  contents  were  admitted  into  the  cavity  filled  with  matter  from  the 
softened  mass.  The  extensive  adhesions  and  agglutinations  of  the  parts  to 
the  anterior  wall  of  the  abdomen  preventing  any  escape  into  the  peritoneal 
cavity,  the  accumulating  matter  was  thus  directed  to  the  surface  where  it 
finally  escaped.  The  right  kidney  seemed  healthy  enough,  but  the  left  was 
so  surrounded  by,  and  pressed  upon,  the  dense  substance  that  it  was  reduced 
in  size  fully  one-half,  but  did  not  appear  to  be  in  the  least  affected  with  the 
invasion  of  cancerous  deposit.  No  part  of  the  intestinal  canal  presented 
any  traces  of  disease,  save  where  the  opening  occurred  in  the  ileum,  and 
there  was  but  one  opening  in  the  ileum,  the  size  of  a  dime,  and  both  the 
openings  through  the  integuments  communicated  with  it,  the  pus  having 
dissected  its  way  under  the  fascia  of  the  abdomen,  and  pointed  at  two  places. 
The  stomach  was  entirely  free  from  disease,  as  were  also  the  liver,  spleen, 
and  pancreas.  But  it  was  in  the  mesentery  that  the  disease  seemed  to  have 
had  its  chief  seat  and  development. 

The  whole  of  the  mesentery,  connected  with  that  portion  of  the  bowel 
implicated,  was  a  mass  of  carcinomatous  matter,  but  the  portion  of  mesen- 
tery attached  to  the  healthy  intestine  was  itself  healthy.  In  the  diseased 
portion  of  the  mesentery,  the  deposit  or  development  of  the  cancerous  mat- 
ter was  chiefly  between  the  folds  of  the  peritoneum,  which  were  distended, 
or  rather  separated  from  each  other,  until  the  peritoneum  was  thrust  away 
from  the  posterior  wall  of  the  abdomen  over  the  spine  and  on  its  left  side, 
and  also  deflected  from  the  intestines  themselves,  until  only  about  one-third, 
and  that  of  course  the  anterior  surface  of  the  bowel,  had  any  peritoneal 
covering  at  all.  A  great  number  of  tumours  were  found  along  the  whole 
course  of  the  spine,  where  the  peritoneum  had  been  pushed  forward  by  their 
growth. 

The  surface  of  the  peritoneum  was  entirely  free  from  any  deposit,  and 
where  the  main  body  of  the  tumour  was  in  contact  with  the  anterior  wall 


266 


American  Intelligence. 


[Jan. 


of  the  abdomen,  the  peritoneum  seemed  merged  in  a  common  blending  of 
all  the  tissues,  and,  perhaps,  in  some  places,  lost  by  absorption  or  ulcera- 
tion, but  not  to  any  appreciable  extent  the  seat  of  deposit. 

Death  during  Convalescence  in  Typhoid  Fever  from  over-eating.  By 
Jas.  L.  Ord,  M.  D.,  of  Santa  Barbara,  California. 

Case  I. — A  young  man  aged  20,  a  native  Californian,  had  a  severe 
attack  of  typhoid  fever  of  about  six  weeks'  duration.  By  giving  several 
times  a  day  large  doses  of  quinia,  with  calomel  gr.  x,  and  tart,  antim.  gr.  j, 
every  third  or  fourth  day,  he  recovered  so  far  as  to  be  able  to  walk  about 
the  house;  although  very  weak,  still  taking  tonics.  Charged  his  attendants 
to  give  him  a  small  allowance  of  digestible  food  with  a  glass  of  wine  at  a 
meal,  four  times  daily,  which  was  strictly  obeyed  for  a  short  time.  One 
day  he  complained  to  his  mother  of  not  having  enough  to  eat,  and  begged 
her  to  give  him  as  much  as  he  could  eat  at  one  time.  She  very  naturally 
assented,  and  cooked  for  him  a  large  dish  of  dried  codfish  and  potatoes 
mixed  with  eggs  and  fried  in  fat,  of  which  he  ate  very  plentifully.  This 
was  in  the  afternoon.  Next  morning  I  was  sent  for  in  a  great  hurry,  and 
was  informed  by  the  messenger  that  my  patient  was  dying — that  he  had 
been  vomiting  for  several  hours,  and  that  if  I  did  not  hurry  he  would  be 
dead  before  I  reached  him.  Sure  enough,  when  I  arrived  I  found  him  in 
articulo  mortis.    No  post-mortem  examination  was  made. 

Case  2. — A  young  man  aged  25,  a  native  Californian,  was  sick  several 
weeks  with  typhoid  fever.  Got  so  well  that  he  walked  about  the  house, 
and  sometimes  would  visit  the  nearest  neighbours,  yet  quite  feeble  and 
taking  tonics.  He  was  told  to  restrain  himself  from  eating  too  much  at 
a  time,  and  to  eat  such  food  as  he  could  digest  easily.  His  appetite  was 
ravenous,  and  he  often  complained  of  not  eating  sufficient  to  satisfy  his  hun- 
ger. One  afternoon  he  visited  a  friend  near  by,  and  was  induced  to  remain 
for  supper.  His  host  told  him,  very  imprudently,  not  to  starve  himself, 
but  to  eat  as  much  as  he  wanted;  that  he  would  soon  be  well,  and  never 
mind  what  the  doctor  said.  He  did  eat  plentifully  of  the  supper,  such  as 
it  was — roast  beef  and  fried  beans.  The  consequence  was  that  he  brought 
on  enteritis,  and  in  forty-eight  hours  he  was  a  corpse. 

j   

DOMESTIC  SUMMARY. 

Ligation  of  the  Subclavian  Artery. — Dr.  H.  N.  Bennett  relates  {Am.  Med. 
Times,  Dec.  27,  1862)  the  following.  A  man  20  years  of  age,  while  playing 
with  a  lad,  was  accidentally  stabbed  with  a  long  narrow  knife,  the  point  of 
which  entered  upon  th*e  posterior  and  outer  face  of  the  left  arm,  a  short  distance 
above  the  insertion  of  the  deltoid,  passing  directly  upwards  and  inwards,  a  dis- 
tance of  at  least  three  inches,  the  edge  of  the  knife  being  turned  towards  and 
running  close  upon  the  bone.  My  friend,  Dr.  James  Baldwin,  of  Stratford,  was 
immediately  called,  as  the  hemorrhage  was  profuse.  Upon  his  arrival  the 
patient  was  already  faint  from  loss  of  blood,  and  it  was  not  difficult  at  this  time 
to  arrest  the  bleeding.  A  roller  was  very  judiciously  applied  the  whole  length 
of  the  limb,  and  a  firm  compress  over  the  wound.  This  precaution  was  taken 
as  the  blood  appeared  to  lie  arterial,  and  Dr.  Baldwin  is  quite  positive  that  at 
this  time  there  was  no  pulsation  in  the  radial  artery,  leading  him  to  suspect 
that  this  vessel  was  wounded.  The  hemorrhage  remained  quiescent  several 
days,  when  it  again  broke  out  with  renewed  force,  and  unmistakably  arterial. 
At  this  stage  of  the  case  I  first  saw  the  patient.  The  whole  limb  was  now 
swollen,  the  arm  being  to  a  considerable  extent  infiltrated  with  blood,  while  the 


1863.] 


Domestic  Summary. 


2GT 


forearm  and  hand  were  oedematous.  I  proposed,  before  resorting  to  operative 
procedures,  to  try  the  application  of  persulphate  of  iron,  which  was  approved 
by  the  attending  physician,  and  the  wound  was  filled  with  this  powerful  styptic 
— compression  being  continued  as  before.  The  hemorrhage  has  now  another 
period  of  quiescence,  and  the  swelling  of  the  limb  materially  lessened,  but  upon, 
the  eighth  day  after  the  application  of  the  styptic,  bleeding  again  commenced, 
with  still  greater  violence,  and  was  with  much  difficulty  arrested  by  compres- 
sion. The  limb  immediately  swelled  again,  and  the  oedema  of  the  forearm  and 
hand  was  greater  than  before.  The  patient  was  now  suffering  the  constitu- 
tional effects  of  loss  of  blood — his  face  was  blanched,  his  appetite  poor,  and 
his  pulse  frequent  and  feeble.  I  believed  it  high  time  to  secure  the  patient 
from  further  hemorrhage,  if  possible,  and  with  this  view  proposed  to  ligate  the 
subclavian  artery.  An  attempt  to  tie  the  wounded  vessel  by  following  the  in- 
cision (only  three-fourths  of  an  inch  in  width),  would  involve  the  muscles  of  the 
arm  to  an  unwarrantable  extent,  and  perhaps  also  important  nerves.  It  was 
quite  uncertain  as  to  what  artery  had  been  severed  or  wounded,  and  the  anasto- 
moses about  the  shoulder  being  quite  free,  I  believed  the  ligation  of  the  sub- 
clavian to  be  the  most  judicious  method  of  treatment.  I  was  not  aware,  either 
theoretically  or  •practically,  that  the  ligation  of  arteries  at  a  distance  from  the 
seat  of  the  wound,  sometimes  fails,  the  hemorrhage  returning  after  a  longer  or 
shorter  period ;  but  this  fact  seemed  to  me  to  indicate  the  tying  of  the  artery  at 
that  point  which  would  most  effectually  restrain  the  circulation. 
•  I  proceeded  to  the  operation  (Oct,  12,  1862),  assisted  by  Dr.  Baldwin.  No 
details  are  necessary,  as  the  vessel  was  tied  in  the  usual  manner  and  place,  just 
without  the  scaleni  muscles.  The  infiltration  of  blood  and  the  oedema  disap- 
peared almost  entirely  within  forty-eight  hours,  and  the  temperature  of  the  limb 
was  easily  maintained  by  an  envelope  of  flannel.  The  ligature  came  off  on  the 
thirteenth  day,  the  operative  incision  being  nearly  healed.  The  original  wound 
also  began  to  cicatrize,  and  was  firmly  closed  at  the  end  of  three  weeks  after  the 
operation.  No  pulsation  is  yet  visible  in  the  radial  or  ulnar  arteries,  although 
the  man  is  in  good  health,  and  pursuing  his  ordinary  avocation. 

Vinegar  as  an  Anti-Scorbutic. — Dr.  Alex.  McBride,  Surgeon  40th  Reg.  0. 
Y.  L,  states  (Cincinnati  Lancet  and  Observer,  July,  1862),  that  he  has  em- 
ployed vinegar  with  great  benefit  in  scurvy. 

His  field  of  duty  was  chiefly  with  the  40th  Reg.  0.  Y.  I.  "  In  January,  and 
the  first  days  of  February,"  he  says,  "the  regiment  was  encamped  at  Camp 
Buell;  a  muddier,  wetter,  and  gloomier  place  than  which  probably  never  existed. 
When  I  found  that  to  procure  potatoes,  cabbage,  citric  acid,  etc.,  was  impos- 
sible, while  the  exciting  causes  and  the  primary  symptoms  of  scorbutus  were 
rampant,  the  prospect  before  me  was  horrible  for  the  suffering  and  death  which 
must  follow." 

In  this  emergency  it  occurred  to  him  to  use  vinegar,  of  which  there  was  an 
abundance  and  of  good  quality  in  the  commissary  department.  He  "immedi- 
ately recommended  and  urged  its  free  and  abundant  use,  and  found  that  it  was 
well  relished  by  every  man,  both  those  on  the  sick  list  and  those  on  duty.  The 
men  were  surprised  to  find  themselves  so  fond  of  vinegar.  I  made  free  use 
of  it.  diluted  with  water,  as  a  common  drink  in  the  hospital  mail  cases  of  disease 
where  the  patient  had  a  relish  for  it,  as  well  in  diarrhoea  and  dysentery  as  in 
common  continued  fever  and  debility.  The  constant  thirst  which  had  been  such 
a  harassing  difficulty,  disappeared,  and  dry  and  parched  mouths  were  by  no 
means  so  common  afterwards.  The  diarrhoea  so  difficult  to  control  was  improved 
in  every  case.  The  indication  in  every  case  for  giving  the  vinegar,  was  the 
relish  for  it.  Thus  had  I  a  remedy,  and  from  this  time  forth  the  diathesis 
changed,  although  there  was  no  other  change  in  the  quality  of  the  rations. 

"  About  a  month  later,  it  became  my  duty  to  prescribe  in  other  regiments  of 
the  brigade,  whose  circumstances  had  been  identical  with  those  of  the  fortieth, 
except  the  vinegar.  The  difference  of  their  health  was  striking ;  the  fortieth 
had  about  fifty  per  cent,  more  men  fit  for  duty  than  either  of  the  other  regiments. 
I  procured  what  vegetables  I  could,  but  the  quantity  was  insignificant  most  of 
the  time." 


268 


American  Intelligence. 


[Jan. 


It  makes  little  difference  how  the  vinegar  is  got  into  the  stomach,  Dr.  McB. 
says,  "  whether  as  a  drink  diluted  with  water,  with  or  without  sugar,  or  mixed 
with  various  articles  of  food.  I  directed  our  men  to  add  it  to  their  bean-soup 
and  to  their  boiled  hominy ;  also,  to  sop  their  bread  in  it,  sweetened  or  not,  ac- 
cording to  taste  or  notion.  Sugar  is  riot  injurious,  but,  I  think,  rather  beneficial 
to  its  effect.  A  very  nice  pie  can  be  made  by  soaking  broken  bits  of  cracker  in 
vinegar,  then  adding  sugar  and  spices,  precisely  as  in  making  apple  pie.  This 
is  as  easy  made  as  apple  pie,  and  eaten  in  the  dark  would  pass  anywhere  for  a 
fruit  pie. 

"  Another  form  :  I  sweeten  good  vinegar  to  taste ;  then  stir  in  flour  or  com- 
mon starch  in  small  quantity,  and  bake  as  a  custard  or  pumpkin  pie." 

[No  fact  in  therapeutics  is  better  established  than  the  anti-scorbutic  pro- 
perties of  vinegar,  and  the  article  is  always  supplied  to  ships  on  long  voyages 
with  that  view;  nevertheless  the  observations  of  Dr.  McB.  are  useful  as  calling 
attention  to  the  article  especially  in  the  scorbutic  condition  into  which  armies 
in  the  field  are  apt  to  fall  where  proper  hygienic  precautions  are  not  observed.] 

Oakum  as  a  Substitute  for  Lint  in  Gunshot  and  other  Suppurating  Wounds. 
— In  our  previous  No.  (pp.  566-67)  we  noticed  the  commendatory  remarks 
of  Dr.  Sayre  on  the  use  of  oakum  as  a  substitute  for  lint,  and  the  grounds 
for  this  preference.  Our  experienced  friend,  Dr.  W.  S.  W.  Kuschenberger, 
dissents  from  the  conclusions  of  Dr.  S.,  and,  in  a  recent  No.  (Oct.  9,  1862)  of 
the  Boston  Med.  and  Surg.  Journal,  he  gives  some  good  reasons  for  his  dissent, 
"  In  order,"  he  says,  "  to  obtain  an  idea  of  the  comparative  absorbent  power 
or  capillary  force  of  oakum,  cotton,  lint,  and  tow,  small  parcels  of  these  articles, 
*  of  ascertained  weight  and  dimensions,  were  gently  placed  on  the  surface  of  water 
in  a  basin,  and  carefully  weighed  again  after  removal.  The  weight  of  water  ab- 
sorbed by  each,  thus  ascertained,  is  stated  in  the  following  table : — 


Cotton  (wool)     .  . 

Tow  (from  hemp) 
Coarse  lint  (shoddy) 
Scraped  lint    .  . 
Patent  lint      .    .  . 

Weight. 

Dimensions. 

Time  in  contact 
with  water. 

Weight  of  water 
absorbed. 

40  grs. 
it 

U 

a 
it 
it 

3  in.  diam. 

2|  " 

H  " 

2A  " 
2£  " 
If  by  3  in. 

1  hour  10  min. 

tt  « 

It  It 

1  minute 
Instantly 
4  minutes 

8  grs.  =  1-5 

io  «  =i 

250  "   =6.25  times 
280  "  =7  " 

298  "  =7.45  " 

299  "  =7.47  " 

"Forty  grains  of  cotton  submerged  and  slightly  squeezed  underwater  for  a 
few  seconds,  was  found  to  retain,  without  dripping,  270  grains;  and  an  equal 
weight  of  oakum  treated  in  the  same  manner,  only  94  grains  of  water.  The 
oakum  retained  little  more  than  twice  its  weight,  and  the  cotton  nearly  seven 
times  its  weight  of  water. 

"  The  inference  from  these  experiments  is  that  the  capillary  force  of  patent 
lint  is  nearly  thirty  times,  and  that  of  tow  twenty-five  times,  greater  than  oakum ; 
and  the  capillary  force  of  oakum  is  only  one-fifth  greater  than  that  of  cotton. 
Oakum  absorbed  one-fourth,  and  cotton  one-fifth,  of  its  weight ;  but  tow  6.25 
times,  coarse  lint  7  times,  scraped  lint  7.45  times,  and  patent  lint  7.47  times,  its 
weight  of  water. 

"  If  the  property  of  capillarity  alone  is  to  determine  the  choice  of  tissue  or 
substance  for  covering  suppurating  wounds,  any  description  of  lint  or  tow  is  to 
be  preferred  to  oakum. 

"  Tow  has  been  long  employed  as  an  outside  dressing  or  recipient  of  profuse 
discharges  ;  and  also  as  a  swab  in  cleansing  offensive  suppurating  wounds,  where 
3ponge  was  not  sufficiently  abundant  to  be  expended  in  this  way.  The  objection 
to  tow  is,  that  there  are  apt  to  be  sharp  or  hard  spiculae  adhering  amongst  its 
fibres,  which  give  pain  when  brought  against  a  sensitive  surface;  but  this  objec- 
tion may  be  obviated  by  carefully  selecting  and  carding  the  substance.  A  better 
substitute  for  sponge  for  cleansing  purposes  in  surgery  is  cotton  wool,  which, 
saturated  with  soapsuds,  or  simply  with  tepid  water,  and  held  in  a  dressing  for- 


1863.] 


Domestic  Summary. 


269 


ceps,  forms  an  admirably  soft  application  that  may  be  used  where  the  finest 
sponge  would  be  found  by  the  patient  rough  and  harsh.  Indeed,  considerations 
of  cleanliness  and  of  avoiding  the  diffusion  of  morbific  matters  from  patient  to 
patient,  suggest  that  sponge  used  once  as  a  detergent  implement  should  not  be 
used  in  the  case  of  any  other  individual,  and  not  too  often  on  the  same  person. 
Cotton  or  tow  forms  a  detergent  implement  so  cheap  that.it  may  be  renewed  at 
every  dressing,  and  ought  to  be  substituted  for  sponge,  without  any  reference 
to  cost,  for  cleansing  purposes. 

"It  is  said  that  cotton  or  lint  placed  over  a  suppurating  wound  serves  to  pre- 
vent the  escape  of  pus,  and  that  oakum  should  be  substituted.  But  it  seems 
that  oakum  as  well  as  lint  may  block  the  way  and  hinder  the  flow  of  the  escap- 
ing liquids,  if  not  removed  when  saturated.  Then  why  should  a  copiously  dis- 
charging wound  be  enveloped  in  any  capillary  material  ?  "Why  not  permit  the 
discharge  to  flow  without  impediment  of  any  kind  ?  Any  contrivance  which 
would  keep  the  wounded  part  at  a  normal  temperature,  whether  in  the  form  of 
oiled  silk,  or  other  tissue  not  readily  permeated  by  moisture,  or  in  shape  of  a 
simple  veil  or  shield  from  flies  in  hot  weather,  might  prove  more  salutary  than 
the  effects  of  a  bunch  or  pledget  of  wiry  oakum  secured  over  it  by  bandage  or 
otherwise. 

"Supposing  that  oakum  possesses  all  the  qualities  claimed  for  it  in  the  in- 
stances specified,  it  cannot  be  regarded  as  a  substitute  for  patent  lint,  because 
there  is  often  necessity  for  just  such  a  pliant  tissue  to  serve  as  the  vehicle  in 
the  application  of  ointments  to  morbid  surfaces — such  as  blisters,  for  example. 

"Substitutes  are  almost  always  defective  expedients.  Whether  they  are 
adopted  from  parsimony,  poverty,  or  other  reason,  they  rarely  satisfy  the  re- 
quirements they  are  employed  to  meet.  The  workman  who  uses  implements  in ' 
all  respects  adapted  to  his  vocation  produces  more  perfect  results  than  he  who 
labours  with  a  paucity  of  tools,  and  hence,  driven  to  expedients,  is  compelled 
to  require  from  his  awl  the  work  of  a  gimlet. 

"  Oakum  is,  doubtless,  applicable  as  a  substitute  to  some  ends.  It  may  an- 
swer as  an  external  dressing,  a  mere  recipient  of  liquid  discharges  ;  but  for  such 
purposes,  as  it  costs  much  more  and  has  less  capillarity,  it  is  a  poor  substitute 
for  tow.  Its  application  to  the  uses  to  which  patent  lint  is  especially  adapted 
could  be  suggested  only  where  no  soft  tissue  is  procurable.  Canton  flannel 
would  answer  the  place  of  patent  lint  better  than  oakum  ;  but,  comparing  their 
adaptability  to  the  object  in  view,  the  propriety  of  substituting  Canton  flannel, 
at  thirty-five  cents  the  square  yard,  for  patent  lint,  while  this  is  procurable  at 
forty  cents,  does  not  commend  itself  to  notice." 

Croup  —  Tracheotomy — Fatal  Result. — Dr.  Jacobi  presented  to  the  New 
York  Pathological  Society  (Sept.  10,  1862)  the  respiratory  organs  of  a  child 
two  years  of  age,  who  died  ten  o'clock  of  the  night  before  of  croup.  He  related 
the  following  history  of  the  case :  I  first  saw  the  child  in  consultation  last  Fri- 
day morning.  He  had  been  suffering  for  about  ten  or  twelve  days  from  nasal 
and  laryngeal  catarrh,  and  when  the  attending  physician  was  called,  twenty-four 
hours  before  I  saw  the  child,  there  were  well  established  symptoms  of  croup.  Not 
only  was  there  more  or  less  occlusion  of  the  larynx,  but  also  diphtheritic  mem- 
branes covering  the  tonsils  and  the  adjoining  parts  of  the  pharynx.  The  physi- 
cian made  use  of  the  usual  remedies,  but  the  symptoms  grew  more  and  more 
grave  every  hour,  and  when  I  was  summoned  suffocation  seemed  so  imminent 
that  I  thought  it  best  to  resort  to  tracheotomy  at  once.  The  operation  was 
performed  in  the  usual  way,  with  the  exception  that  the  incision  into  the  trachea 
was  made  through  the  thyroid  body.  The  hemorrhage  which  followed  this  pro- 
cedure was  very  much  less  than  I  expected  it  would  be. 

The  operation  under  the  circumstances  was  considered  justifiable,  inasmuch 
as  I  could  not  make  out  there  was  any  pneumonia  present.  About  twenty 
minutes  after  the  operation  the  child  breathed  pretty  well,  and  pulse  ranged 
from  135  to  140  per  minute.  The  pulse  increased  in  frequency  until  the  after- 
noon when  it  was  about  150.  The  child  then  took  a  little  of  Horwood's  tinct. 
of  veratrum  viride,  a  drop  every  two  hours,  and  the  following  morning  appeared 
evidently  better,  there  being  no  positive  symptoms  of  bronchitis  present.  During 


270 


American  Intelligence. 


[Jan. 


that  afternoon  there  was  a  sudden  collapse.  The  use  of  stimulants  and  quinine 
soou  reduced  the  pulse  from  190  to  its  former  frequency,  and  gave  us  some  hope 
for  a  recovery.  On  the  morning  of  the  third  day,  however,  symptoms  of  suffo- 
cation began  to  show  themselves,  and  the  child  would  throw  out  from  time  to 
time  hard  shreds  of  mucous  membrane  with  a  temporary  relief  of  the  symptoms. 
The  percussion  sound  was  normal  and  clear  posteriorly,  but  somewhat  duller 
than  usual  anteriorly.  The  symptoms  of  suffocation  gradually  grew  more  and 
more  manifest,  and  the  child  died  last  evening  in  about  the  same  condition  as  he 
would  have  died  from  the  first  attack  of  croup.  I  have  to  state  that  one  of  the 
attempts  to  cure  consisted  in  introducing  a  pretty  strong  solution  of  nitrate  of 
silver.  This  was  done  day  before  yesterday  at  intervals  of  thirty-six  and  twelve 
hours  before  death.  After  the  first  attempt  the  child's  breathing  seemed  to  be 
less  embarrassed,  especially  after  some  of  the  shreds  of  membrane  were  torn  out 
by  the  feather  containing  the  solution. 

A  portion  of  the  larynx,  pharynx,  and  trachea  were  then  exhibited.  Portions 
of  the  tonsils  and  the  whole  larynx  were  covered  with  pseudo-membranes,  which 
did  not  show  any  disposition  to  separate.  The  wound  made  by  the  operation 
was  so  covered  by  this  membrane  above  and  below  that  the  process  of  healing 
had  progressed  very  slowly.  The  evidences  of  tracheitis  were  very  well  marked. 
The  membranous  shreds  could  be  traced  down  as  far  as  the  bifurcation  of  the 
bronchial  tubes.  The  lungs  were  healthy,  with  the  exception  that  on  the  left 
side  there  were  pleuritic  adhesions  and  several  marks  of  pulmonary  apoplexy. — 
Am.  Med.  Times,  Dec.  20,  1862. 

Black  Calculus  from  the  Kidney. — Dr.  White  read  before  the  Boston  Society 
•  for  Medical  Improvement  (Sept.  22)  the  following  report  of  an  analysis  of  a 
black  calculus  which  was  shown,  lying  in  the  kidney,  by  Dr.  J.  Wyuian,  at  a 
former  meeting.  Shape,  obtuse  almond.  Weight,  40  grains.  Length,  10  lines. 
Width,  6  lines.    Thickness,  4  lines. 

Its  surface  is  almost  wholly  covered  with  well-marked,  conical  papillae  and 
crystalline  projections,  and  is  of  an  in  tensely*  black  colour,  with  the  exception 
of  two  small,  deltoid-shaped  portions.  These  are  of  a  yellowish-white  colour, 
and  are  situated  upon  one  of  the  flat  surfaces,  their  acute  angles  nearly  meeting 
in  the  centre,  and  forming  a  depressed  girdle,  by  which  constriction  the  stone 
was  tightly  held  within  the  sac,  from  which  it  only  half  projected,  and  was  with 
difficulty  removed.  The  black  substance  is  hard,  shiny  in  places,  and  not  easily 
detached.  It  is  deposited  in  a  uniform  layer,  nowhere  exceeding  one-third  of  a 
line  in  thickness. 

Portions  of  this  matter,  examined  by  the  microscope,  were  found  to  be  so 
deeply  coloured  as  to  possess  no  transparency.  Treated  with  concentrated  acetic 
and  sulphuric  acids  they  remained  entirely  unchanged.  Hydrochloric  acid 
appeared  to  have  no  other  effect  upon  them  than  to  extract  a  little  oxalate  of 
lime,  which  forms  the  principal  part  of  the  substratum,  upon  which  the  colour- 
ing matter  rests.  In  alcohol  and  ammonia  alike  unaffected.  Boiled  with  a 
strong  solution  of  potash,  the  liquid  assumed  a  brown  colour,  which  on  cooling 
deposited  an  amorphous,  dark-coloured  matter,  and  became  colourless  again. 
The  fragments  thus  treated  were  changed  to  a  deep  yellowish-brown,  and  ex- 
hibited a  concentric,  lamellated  structure,  some  of  the  layers  representing  circles 
of  small  diameter.  Nitric  acid,  concentrated,  produced  a  brisk  effervescence, 
and  very  gradually  destroyed  the  black  colouring  matter,  leaving  behind  an 
orange-tinted,  uniform  tissue,  of  the  original  shape  and  size.  After  spontaneous 
evaporation  various  crystalline  forms  were  observed,  some  of  which  were  of  a 
yellow  colour,  but  in  too  small  quantity  to  admit  a  satisfactory  examination.  A 
careful  analysis  was  made  of  as  much  of  the  black  matter  as  it  was  thought  well 
to  remove,  for  iron,  but  the  most  delicate  tests  failed  to  discover  its  presence. 

What,  then,  is  this  peculiar  substance?  It  might  at  first  be  taken  for  haema- 
tine  or  some  of  its  modifications,  perhaps  melanine;  but  all  the  blood  pigments, 
as  is  well  known,  contain  iron,  and  not  a  trace  of  this  metal  was  discoverable  in 
the  portion  examined,  nor  do  the  results  of  the  above  tests  at  all  agree  with  the 
ordinary  reactions  of  such  substances.  It  would  be  a  very  interesting  point, 
moreover,  to  determine  whether  the  patient  ever  was  affected  with  haematuria, 


1863.] 


Domestic  Summary. 


2U 


and  even  if  lie  had  been,  it  seems  impossible  that  so  black  a  pigment  could  be 
formed  from  the  coagulation  of  blood.  Whether  we  are  dealing  with  simple 
colouring  matter,  accidentally  mixed  with  some  fibrinous  or  albuminoid  sub- 
stance, which  forms  the  chief  proportion  of  the  layer,  as  shown  by  the  experi- 
ments given,  or  whether  the  two  are  one  unknown  body,  it  is  impossible  to 
decide  with  the  small  amount  of  material  at  command.  The  latter,  however, 
seems  by  far  the  more  probable,  for  I  have  never  seen,  nor  heard  of,  a  similar 
substance  of  any  colour  as  a  constituent  of  a  urinary  calculus. 

If,  then,  we  give  up  the  blood  as  the  origin  of  its  formation,  can  we  turn  to 
the  urine  more  hopefully  for  a  solution  ?  I  believe  not,  if  we  limit  its  resources 
to  the  production  of  the  colouring  matters  already  known,  and  as  exhibited  in 
normal  or  abnormal  conditions ;  for  it  has  no  resemblance  to  urophsein,  uroxan- 
thin,  or  uroerythrin.  Moreover,  the  darkest  known  pigments  the  urine  is  capable 
of  producing,  are  those  imparted  to  crystals  of  uric  acid,  and  those  which  colour 
certain  oxalate  of  lime  calculi ;  but  neither  of  them  even  approach  in  intensity 
the  unique  specimen  now  before  us.  The  results  of  our  analysis,  therefore,  are 
negative  only,  and  with  such  we  must  rest  satisfied,  for  perhaps  nothing  more 
definite  would  result  from  the  employment  and  destruction  of  the  entire  specimen. 

Coating  the  surfaces  of  the  triangular  facets,  which  were  protected  from  the 
deposition  of  pigment  by  contact  with  the  lips  of  the  sac,  is  a  layer  of  yellowish- 
white  material,  composed  chiefly  of  organic  matter.  By  the  microscope,  large 
masses  of  round  cells  are  seen,  filled  with  a  fluid,  colourless  fat,  and  encrusted 
with  carbonate  of  lime.  On  the  addition  of  any  fluid,  the  cell  walls  burst,  and 
allow  the  fat  in  large  quantities  to  float  away.  When  treated  with  acid,  thin, 
membranous  flakes  are  observed,  which,  with  the  aggregation  of  fat  cells,  are 
undoubtedly  portions  of  the  kidney  or  cyst,  which  had  undergone  fatty  degenera- 
tion.   From  the  same  portions,  oxalate  of  lime  was  also  extracted. 

On  boring  into  the  centre  of  the  calculus,  from  this  point,  its  interior,  the 
great  body  of  the  stone,  in  fact,  was  found  to  be  of  a  hard,  gritty  nature,  and  of 
a  grayish-white  colour.  This  was  found,  on  analysis,  to  consist  of  large  crystals 
of  oxalate  of  lime,  resembling,  beneath  the  microscope,  angular  fragments  of 
silica,  together  with  a  small  portion  of  carbonate  of  lime. 

To  review,  then,  the  calculus  is  composed  of — 1st,  an  outside  layer  of  some 
unknown  black  colouring  matter;  2d,  of  portions  of  metamorphosed  animal  tis- 
sue ;  3d,  of  oxalate  and  carbonate  of  lime. — Boston  Med.  and  Surg.  Journ., 
Nov.  6,  1862. 

Case  of  Poisoning  from  the  Pollen  of  the  Common  Yellow  Tiger  Lily. — Dr. 
Jeffries  Wyman  read  before  the  Boston  Society  for  Medical  Improvement 
(Oct.  27th)  the  following  report  of  a  case  by  Dr.  R.  T.  Warren,  of  Waltham, 
•Mass. : — 

"  Mrs.  B.  was  making  a  call  at  a  neighbour's,  having  with  her  a  little  daughter, 
4  years  old.  The  child  was  'perfectly  well,'  the  mother  said,  and  had  been  so. 
It  played  with  another  little  girl,  and  did  not  go  out  of  the  room  during  the  call. 
The  little  girl  came  to  Mrs.  B.,  requesting  her  to  go  and  see  Fanny,  the  name  of 
the  child.  Mrs.  B.  went,  and  found  Fanny  rubbing  her  nose  very  violently. 
Soon  there  was  a  profuse  discharge  of  mucus  from  the  nose,  coloured  yellow. 
The  mother  questioned  the  child,  and  ascertained  that  she  had  reached  her 
hand  out  of  the  window,  taken  an  anther  from  a  tiger  lily,  and  passed  it  into  the 
right  nostril.  The  child  pointed  out  the  lily,  and  the  mother  found  just  one 
anther  missing.  Mrs.  B.  was  particular  in  her  inquiries,  and  the  child  was  posi- 
tive in  stating  what  she  had  done.  Yomiting  soon  followed  the  discharge  of 
mucus  from  the  nose.  This  consisted  at  first  of  chyme,  having  no  appearance  of 
undigested  food,  and  was  followed  by  vomiting  of  mucus,  coloured  yellow,  the 
same  as  the  discharge  from  the  nose.  The  child  then  wanted  to  go  to  sleep.  The 
mother  took  her  home,  and  then  sent  for  me.  I  saw  her  at  6  P.  M.,  Wednesday, 
August  13,  about  an  hour  after  the  anther  was  passed  into  the  nose.  The  child 
appeared  sleepy,  but  was  easily  roused,  and  was  intelligent.  Yomiting  of  mucus, 
tinged  yellow,  occurred  while  I  was  present.  The  yellowness  did  not  seem 
to  be  caused  by  bile.  The  symptoms  did  not  seem  at  all  alarming.  Not  aware 
that  the  tiger  lily  possessed  any  poisonous  properties,  I  felt  no  anxiety,  and 


272 


American  Intelligence. 


[Jan.  1863.] 


went  away,  after  prescribing  remedies,  requesting  to  be  called  if  anything  new 
occurred.  I  was  sent  for  about  10  P.  M.,  four  hours  afterwards.  Evacuations 
of  the  bowels  had  occurred;  at  first  of  natural  appearance,  then  followed  dis- 
charges coloured  yellow,  the  same  as  the  vomiting  and  the  discharge  from  the 
nose,  and  at  last  bloody  discharges.  The  vomiting  had  occurred  occasionally, 
and  this  at  last  became  bloody.  The  child  was  dull,  sleepy,  and  languid,  1 
prescribed  astringents,  opiates  in  the  form  of  paregoric,  and  brandy  and  water, 
if  the  languor  should  increase.  I  saw  her  Thursday  morning.  A  dejection,  quite 
bloody,  occurred  between  1  and  2  o'clock  A.  M.,  and  after  that  the  dejections 
were  checked.  She  was  relieved  of  the  vomiting.  The  child  seemed  ianguid, 
rather  sleepy ;  no  wandering.  The  eyes  had  a  dull,  reddish  injection.  At  4 
P.M.,  same  day,  appearance  of  the  child  much  the  same  as  in  the  morning.  The 
right  nostril  was  nearly  closed ;  membrane  of  both  nostrils  very  pale.  Some 
discharge  of  clear,  thin  mucus.  Friday  morning. — The  child  looked  brighter. 
Same  reddish  injection  of  the  eyes.  No  urine  had  been  passed  during  the  last 
twenty-four  hours.  Slight  feverish  symptoms.  No  delirium.  7  P.  M.,  Friday. — 
No  urine  had  been  passed.  Several  dejections,  dark  coloured,  very  offensive. 
Some  fever  during  the  day,  slight  delirium  and  startings.  Some  nausea,  Was 
called  to  her  about  1  o'clock,  Saturday  morning.  Shortly  before  she  had  a  large, 
dark-coloured,  very  offensive  discharge,  and  immediately  began  to  sink.  She 
died  a  little  before  4  o'clock,  about  fifty-nine  hours  after  passing  the  anther  into 
the  nostril." — Boston  Med.  and  Surg.  Journ.,  Nov.  6,  1862. 

Can  Pregnancy  follow  Defloration  in  Rape,  when  force  simply  is  used? — 
This  question  is  discussed  by  Dr.  E.  S.  F.  Arnold,  of  Yonkers,  in  a  late  No. 
(Nov.  29th)  of  the  Am.  Med.  Times.  He  maintains  with  plausibility  that  it 
is  "  as  impossible  for  a  woman  to  conceive  while  under  the  influence  of  terror, 
shock,  and  nervous  exhaustion,  as  it  would  be  for  a  man  to  perform  the  act 
of  intercourse  while  prostrated  by  similar  agencies. 

"  As  might  be  supposed,  the  same  influences  affect  powerfully  the  uterus  dur- 
ing the  whole  after  period  of  gestation.  What  is  more  likely  to  produce  mis- 
carriage than  a  fright,  or  any  sudden  shock  to  the  nervous  system  ?  Is  it  then 
reasonable  to  suppose,  that  while  terror,  or  strong  and  painful  emotions,  espe- 
cially those  of  a  sudden  character,  will  affect  the  uterus  so  powerfully  as  to  cause 
it  to  lose  its  contents,  that  it  can  be  independent  of  them  during  coitus ;  that  it 
shall,  in  fact,  be  independent  of  them  at  one  moment  only  to  become  peculiarly 
sensitive  to  them  from  that  time  forward  ? 

"While  then  the  uterus  is  admitted  to  be  sufficiently  independent  of  the  mere 
will,  it  certainly  cannot  be  proved  that  conception  may  occur  during  a  first  and 
forcible  coitus,  by  citing  cases  to  show  that  it  may  follow  the  exhibition  of  nar- 
cotics or  sedatives ;  on  the  contrary,  to  reach  such  a  case  as  I  have  started  with 
at  the  commencement  of  this  article,  we  have  to  show  that  it  may  occur  under 
circumstances  of  an  entirely  opposite  character,  viz.,  those  of  intense  and  over- 
whelming excitement  of  a  painful  kind.  I  can  believe  that  a  woman  of  virtuous 
impulses  may  be  so  overcome  by  passion  excited  in  resisting  a  sudden  assault, 
that  a  vigorous  opposition  may  subside  into  passive  submission,  and  that  im- 
pregnation may  result,  but  then  she  becomes  a  consenting  party  in  the  eye  of 
the  law.  It  is  not  a  rape.  I  can  also  readily  conceive  that,  impelled  by  shame, 
she  may  stoutly  assert  that  she  had  resisted  to  the  extent  of  her  power,  and  her 
antecedents  and  subsequent  conduct  may  lend  undue  weight  to  her  statements 
in  the  absence  of  positive  proof,  which  it  is  impossible  to  obtain.  The  older 
writers,  then,  may  not  be  so  far  wrong  after  all,  when  they  assert  that  pregnancy 
shows  consent  (at  least  where  no  other  means  than  actual  exertion  of  strength 
to  accomplish  the  act  are  used),  that  is,  such  consent  as  would  reduce  the  crime 
from  that  of  rape  in  law  to  a  mere  assault." 

Rupture  of  Uterus;  Ccesarean  Section. — Dr.  L.  R.  Holmead  records  ( Chicago 
Med.  Journ.,  Dec.  1802)  a  case  of  rupture  of  the  uterus  in  a  fifth  labour,  all  the 
former  ones  having  been  severe  and  prolonged.  Dr.  Byford,  who  was  called  in, 
performed  the  Cesarean  operation  and  extracted  placenta  and  child,  both  of 
which  were  found  in  the  peritoneal  cavity.  It  is  not  stated  whether  the  child 
was  living  or  dead.    The  patient  died  seven  days  after. 


P  L  A  T  E    I . 


^1???.  Journ.  Med.  Sci.,  vol.  lxxxix. 


Am.  Journ.  Med.  Set'.,  vol.  Ixxxix.  PLATE  II 


THE 

AMERICAN  JOURNAL 
OF  THE  MEDICAL  SCIENCES 

FOR   APRIL    1  8  6  3. 


Art.  I. — Experiments  connected  with  the  Discovery  of  Cholesterine  and 
Seroline,  as  Secretions,  in  Health,  of  the  Salivary,  Tear,  Mammary, 
and  Sudorific  Glands;  of  the  Testis  and  Ovary;  of  the  Kidneys  in 
Hepatic  Derangements ;  of  Mucous  Membranes  when  congested  and 
inflamed;  and  in  the  Fluid  of  Ascites  and  that  of  Spina  Bifida.  By 
J.  H.  Salisbury,  M.  D.    (With  two  plates  containing  eighteen  figures.) 

I  hate  read,  with  much  interest,  the  able  paper  of  Austin  Flint,  Jr., 
M.  D.,  of  New  York,  entitled  "Experimental  Researches  into  a  New  Ex- 
cretory Function  of  the  Liver;  consisting  in  the  Removal  of  Cholesterine 
from  the  Blood,  and  its  discharge  from  the  body  in  the  form  of  Stercorine;" 
published  in  the  number  of  this  Journal  for  October  last.  0 

Having  in  similar  experiments,  in  which  I  have  been  for  some  time 
engaged,  determined  the  presence  of  cholesterine  and  seroline  (stercorine 
of  Dr.  Flint)  in  other  healthy  secretions  of  the  human  body — in  the  testis 
and  ova  of  the  human  subject — in  the  ova  of  some  animals — and  in  mor- 
bid collections  of  fluid  in  the  human  body,  I  here  present  briefly  results 
which,  so  far  as  I  know,  are  new. 

The  process  followed  for  separating  these  bodies  was,  in  all  essential  par- 
ticulars, similar  to  that  pursued  by  Dr.  Flint,  and  for  which  I  refer  to  his 
able  paper. 

Exp.  f.  Cholesterine  in  human  ova.  —  An  unmarried  woman,  aged 
about  26,  of  strong  constitution,  was  found  dead  in  bed.  On  making  a 
post-mortem  examination,  the  stomach  was  found  highly  inflamed  and 
ruptured.  A  gravid  uterus  was  found,  from  which  a  foetus,  about  three 
months  gone,  had  recently  been  expelled.  Near  the  body  were  found  two 
bottles,  one  containing  chloroform  and  the  other  oil  of  savin.  The  genital 
organs,  stomach,  and  intestines,  were  taken  for  examination.  Oil  of  savin 
was  found  in  the  fecal  matter  of  intestines  and  in  the  contents  of  the 
No.  XC— April  1863.  19 


290        Salisbury,  Cholesterine  and  Seroline  as  Secretions.  [April 


stomach,  which  had  been  emptied  into  the  peritoneal  cavity.  From  all  the 
facts  that  could  be  gathered,  from  the  post-mortem  and  chemical  examina- 
tions, it  appeared  that  the  woman  came  to  her  death  from  taking  oil  of 
savin  to  produce  abortion.  The  abortion  was  effected;  but  so  much  inflam- 
mation and  softening  of  the  stomach  had  been  produced  by  the  oil  of  savin 
that,  during  the  severe  vomiting  the  stomach  was  ruptured  and  death 
ensued.  The  ovaries  were  carefully  washed  and  macerated  in  several 
waters,  to  free  them  from  all  adhering  blood  and  serous  matter;  the 
ovisacs  were  then  one  by  one  punctured  and  their  contents  received  into 
a  porcelain  capsule ;  this  matter  was  evaporated  to  dryness  over  a  water- 
bath,  and  the  residuum  subjected  to  the  process  for  obtaining  cholesterine 
and  seroline.  A  concentrated  hot  alcoholic  solution  of  the  matter  obtained 
was  placed  between  glass  slides  to  gradually  crystallize.  In  a  short  time 
there  appeared  a  beautiful  mass  of  crystalline  plates,  which  proved  to  be 
cholesterine,  a  portion  of  which  is  seen  at  Fig.  9.  A  quantitative  exam- 
ination was  not  made,  but  the  qualitative  revealed  cholesterine  largely  pre- 
sent.   No  crystals  of  seroline  appeared. 

Exp.  2.  Cholesterine  in  ova  of  swine. — The  ovaries  of  pigs  about  six 
months  old  were  taken  and  treated  to  separate  adhering  blood  and  outside 
serous  matter;  the  ovisacs  punctured,  and  their  contents  received  into  a 
large  watch-glass  capsule ;  evaporated  to  dryness  over  a  water-bath,  and 
residuum  subjected  to  the  process  for  obtaining  cholesterine.  The  result 
was  an  abundant  crop  of  crystals,  having  very  much  the  appearance  of 
those  seen  at  Fig.  9,  before  referred  to. 

Exps.  3,  4,  and  5.  Cholesterine  in  Graafian  vesicles,  liquor  amnii, 
and  brain  of  sow. — A  sow,  weighing  525  lbs.,  was  killed  Dec.  1.  She  was 
about  two  years  old,  and  very  fat.  The  uterus  contained  twelve  pigs  that 
had  attained  about  one-fourth  their  foetal  growth.  Removed  for  examina- 
tion, while  the  hog  was  still  warm,  the  following  parts :  brain,  contents  of 
gall-bladder,  liquor  amnii,  and  ovaries.  The  brain  (cerebrum  and  cerebel- 
lum) in  its  warm,  fresh  state,  weighed  3147.59  grains.  The  gall-bladder 
contained  of  dark  amber-colored  bile  2160  grains.  Bile  alkaline,  slightly 
ropy,  and  about  the  consistence  of  sweet  oil  at  90°  F.  Obtained  from  the 
ovisacs  or  Graafian  vesicles  between  forty  and  fifty  drops  of  a  thin  albumi- 
nous fluid,  resembling  the  white  of  a  hen's  egg  in  feel  and  in  coagulating 
properties.  Of  liquor  amnii  there  was  about  four  ounces  to  each  pig.  The 
amniotic  fluid  had  a  slight  straw-yellow  colour,  was  clear,  and  almost  as 
limpid  as  water.   It  had  an  alkaline  reaction,  and  the  odor  of  fresh  serum. 

Subjected  forty  drops  of  the  fluid  from  the  Graafian  vesicles  to  the  pro- 
cess for  determining  the  presence  of  cholesterine.  Obtained  a  small  crop 
of  well-defined  crystals  resembling  those  seen  at  Fig.  9. 

The  liquor  amnii,  on  cooling  and  standing  in  a  porcelain  evaporating 
dish  for  about  six  hours,  contained  on  its  surface  a  thin  iridescent  pellicle 
fissured  by  several  sets  of  cleavage  lines,  which  were  often  parallel  to  each 
other,  and  the  different  sets  crossing  either  at  acute  or  right  angles.  This 
pellicle  proved  to  be  cholesterine. 

300  grains  of  the  fresh  brain  (about  equal  parts  of  cerebrum  and  cere- 
bellum, gray  and  white  matter)  were  taken  and  subjected  to  the  process  for 
obtaining  the  cholesterine.  The  result  weighed  3.89T  grains.  Percentage 
of  cholesterine  in  fresh  brain  1.299.  The  cholesterine  as  obtained  had  a 
beautiful  white  pearly  lustre  and  crystalline  appearance  to  the  unaided  eye. 
Undissolved  in  ether  and  allowed  to  crystallize  slowly  between  glass  slides, 
the  crystals  under  the  microscope  had  the  appearance  seen  at  Fig.  10. 


1863.]     Salisbury,  Cholesterine  and  Seroline  as  Secretions.  291 


Exp.  6.  Cholesterine  in  bile  of  sow. — Subjected  800  grains  of  the  fresh 
bile  from  the  sow  to  the  process  for  obtaining  the  cholesterine.  The  result 
weighed  5.614  grains.  Percentage  of  cholesterine  .102.  The  cholesterine 
had  a  white  pearly  lustre  and  crystalline  appearance.  Redissolved  in  ether 
and  allowed  to  crystallize  slowly  between  glass  slides.  The  crystals  had 
the  appearance  seen  at  Fig.  7.  Many  of  the  plates  were  very  long  and 
narrow. 

Exp.  t.  Ova  of  hen.— ^ About  half  of  the  yolk  of  a  fresh,  newly-laid 
hen's  egg  was  evaporated  to  dryness  carefully  over  a  water-bath,  and  the 
residuum  proceeded  with  for  obtaining  cholesterine  and  seroline.  The  re- 
sult was  an  abundant  crop  of  crystals  between  the  glass  slides,  a  portion 
of  which  is  seen  at  Fig.  1.  The  crystals  were  large  and  less  rhomboidal 
than  in  the  previous  experiments.    No  seroline  was  found. 

Exp.  8.  Ova  of  black  bass.  —  About  one  ounce  of  the  ova  of  a  large 
black  bass  (weight  about  eight  lbs.)  was  examined  in  the  usual  way  for 
cholesterine  and  seroline.  After  the  final  concentrated  hot  alcoholic  solu- 
tion had  evaporated  between  glass  slides,  it  was  examined  microscopically 
and  found  to  contain  a  beautiful  and  abundant  crop  of  cholesterine,  a  por- 
tion of  which  is  seen  at  Fig.  2.  The  crystals  were  very  large,  and  more 
rectangular  than  those  from  the  human  ova.    No  seroline  was  found. 

Exp.  9.  In  the  ovisac  of  the  black  bass  described  in  the  previous  expe- 
riment were  two  large  ragged  calculi,  one  3^  inches  long  and  1J  inches  in 
diameter.  They  were  covered  with  an  iridescent  membrane,  resembling  in 
appearance  the  metallic  iridescence  on  the  surface  of  the  fish.  These  cal- 
culi were  examined  for  cholesterine  and  seroline,  and  were  found  to  contain 
the  former  in  much  larger  quantity  than  the  ova.  The  crystals  had  the 
same  appearance  as  those  seen  at  Fig.  2.    No  seroline  was  found. 

Exp.  10.  Seminal  fluid. — Procured  from  a  strong  healthy  man,  aged 
about  35,  two  drachms  of  seminal  fluid.  Evaporated  to  dryness  over  a 
water-bath  and  proceeded  with  the  residuum  in  the  usual  way  for  obtaining 
cholesterine  and  seroline.  The  final  alcoholic  solution,  on  evaporating 
between  glass  slides,  was  found  to  be  composed  of  an  abundant  crop  of 
crystals,  a  sample  of  which  is  seen  at  fig.  5.  The  amount  of  cholesterine 
was  large,  considering  the  quantity  of  material  operated  upon,  but  the 
crystals  were  small,  as  seen  at  a ;  a  large  proportion  of  the  crystalline 
matter,  however,  was  seroline,  having  the  appearance  of  the  crystals  seen 
at  b  and  c.  Some  of  these  crystals  are  seen  to  be  rhomboidal,  very  acutely 
so,  as  at  c. 

Exp.  11.  Saliva. — Evaporated  to  dryness  and  examined  for  cholesterine 
and  seroline,  two  ounces  of  healthy  saliva.  Evaporated  it  over  a  water- 
bath  in  a  broad,  flat-bottomed  porcelain  dish ;  so  that  in  thirty  minutes 
after  it  was  secreted  the  evaporation  was  complete.  The  saliva  was  from 
a  strong  healthy  man,  in  the  prime  of  life,  who  neither  indulged  in  chewing 
or  smoking  tobacco,  or  in  the  drinking  of  intoxicating  liquors.  On  placing 
the  final  alcoholic  solution  between  glass  slides,  there  was  soon  produced  a 
large  and  beautiful  crop  of  cholesterine  crystals,  the  appearance  of  a  por- 
tion of  which  is  seen  at  Fig.  6.  A  quantitative  examination  was  not  made, 
but  the  qualitative  analysis  demonstrated  it  largely  present  in  the  saliva  ; 
apparently  almost  as  abundant  in  this  secretion  as  in  the  bile.  No  crystals 
of  seroline  were  found. 


292        Salisbury,  Cholesterine  and  Seroline  as  Secretions.  [April 


Exp.  12.  Secretion  from  congested  and  inflamed  mucous  membrane. — 
A  strong  healthy  man  contracted  a  severe  cold  from  sleeping  in  a  damp 
room.  About  forty-eight  hours  after,  the  mucous  membrane  of  the  fauces 
and  nose  became  so  congested  and  inflamed  that  a  thin,  watery,  transparent 
fluid  flowed  from  the  nostrils  at  the  rate  of  about  two  drops  per  minute. 
About  one  ounce  of  this  fluid  was  collected.  Under  the  microscope  each 
drop  was  found  to  contain  about  200  mucus  cells  and  100  colourless  blood- 
disks.  The  one  ounce  was  carefully  evaporated  to  dryness  over  a  water -bath 
and  the  residuum  treated  in  the  usual  way  for  obtaining  cholesterine  and 
seroline.  The  presence  of  cholesterine  was  demonstrated  in  small  quantity, 
much  less  than  in  the  serum  of  the  blood. 

Exp.  13.  Bronchial  mucus. — Took  two  ounces  of  bronchial  mucus  ex- 
pectorated by  a  patient  labouring  under  severe  chronic  bronchial  disease,1 
and  subjected  it  to  the  process  for  determining  the  presence  of  cholesterine 
and  seroline.  A  very  small  quantity  of  cholesterine  was  obtained,  the 
appearance  of  which,  as  crystallized  between  the  glass  slides,  is  seen  at 
Fig.  8,  a  and  b.  The  crystal  at  b  is  split  at  the  ends,  like  the  crystals  of 
cholesterine  found  in  the  fluid  of  ascites,  seen  at  Fig.  3,  a  and  b.  The 
same  form  of  crystal  also  occurs  in  jaundice  urine.  There  was  also  found 
a  small  quantity  of  the  peculiar  crystalline  matter  seen  at  c,  Fig.  8,  and 
the  bent  prisms  seen  at  d.  From  the  small  quantity  of  cholesterine  found, 
it  is  probable  that  what  there  was  came  mostly  from  the  small  amount  of 
saliva  which  necessarily  would  become  mixed  with  the  bronchial  mucus  in 
its  passage  through  the  mouth.  The  crystalline  matter  seen  at  c  and  d  did 
not  occur  in  the  saliva  examined.  It  is  fair,  therefore,  to  infer  that  it  be- 
longs to  the  bronchial  mucus.  The  bronchial  mucus  was  very  thick,  ropy, 
and  white,  having  the  appearance  of  coagulated  albumen.  It  was  quite 
acid.    No  pus  present. 

Exp.  14.  Serous  fluid. — Examined  for  cholesterine  and  seroline  the 
serous  fluid  from  the  peritoneal  cavity  iu  a  case  of  ascites  in  a  female  aged 
73.  "  Liver  extensively  diseased.  Had  abscess  a  year  ago,  which  pointed 
and  discharged  copiously  at  umbilicus.  The  dropsical  effusion  rapidly  ac- 
cumulated up  to  Nov.  12th,  when  she  was  tapped."2 

The  fluid  had  a  milky  appearance,  and  was  thin  and  watery ;  slightly 
acid.  Evaporated  five  ounces  of  the  fluid  to  dryness  over  a  water-bath,  and 
subjected  the  residuum  to  the  process  for  determining  the  presence  of  cho- 
lesterine and  seroline.  The  final  alcoholic  solution  gave,  on  being  gradu- 
ally evaporated  between  glass  slides,  some  fine  groups  of  crystals,  samples 
of  which  are  seen  at  Fig.  3,  a,  b,  c,  d.  Those  at  d  represent  the  usual 
form  of  cholesterine  crystals ;  several  groups  presented  the  narrow  radiating 
tablets  seen  at  c,  and  still  others  had  the  appearance  of  those  at  a  and  b, 
the  extremities  of  the  plates  being  divided  and  bent. 

Exp.  15.  Fluid  of  spina  bifida  tumour. — Three  ounces  of  fluid3  from 
a  spina  bifida  tumour  in  a  child,  was  evaporated  to  dryness  carefully  over 

1  This  patient  was  attended  by  Dr.  Boerstler,  to  whose  kindness  I  am  indebted 
for  furnishing  the  expectorated  mucus  for  examination. 

2  I  am  indebted  to  the  kindness  of  Dr.  Effinger,  of  Lancaster,  0.,  for  the  report 
of  this  case,  and  the  fluid  furnished  for  examination. 

3  Kindly  furnished  by  Dr.  Boerstler,  of  Lancaster,  O.,  to  whom  I  am  indebted 
for  many  similar  favours. 


1863.]     Salisbury,  Cholesterine  and  Seroline  as  Secretions.  293 


a  water-bath,  and  treated  further  in  the  usual  way  for  discovering  choles- 
terine and  seroline.  The  fluid  was  slightly  alkaline.  Cholesterine  was 
demonstrated  to  be  present  in  considerable  quantity. 

A  portion  of  the  fluid  was  examined  carefully  under  the  microscope.  It 
was  thin,  watery,  and  milky,  with  numerous  white  flocks  floating  though  it. 
These  flocks  under  a  low  power  (200  diameters)  presented  the  appearance 
of  fragments  of  milk  curd.  Under  a  higher  power  (600  diameters)  they 
were  resolved  into  the  bodies  mentioned  below.  Many  of  the  "  milk  curd 
masses"  were  composed  of  nerve  tiibuli.  Occasionally  was  found  a  tuber- 
culated  cell  filled  with  fluid,  and  met  with  in  most  animal  and  vegetable 
tissues,  and  resembling  somewhat  some  varieties  of  pollen  grains.  There 
were  also  found  numerous  spherical  fungoid  spores,  aggregated  in  flocks,  and 
among  them  was  noticed  a  single  elongated  vegetating  spore.  Scattered 
through  the  fluid,  quite  abundantly,  were  flattish  oblate  spheroidal,  highly 
refractive  cells  of  various  sizes,  many  of  the  larger  of  which  had  the  ap- 
pearance of  being  ruptured  on  the  side.  Occasionally  one  was  met  with 
containing  small  reddish-brown  spherical  cells. 

In  the  flocks  mentioned  above  were  many  remains  of  disintegrating  cells. 
There  were  also  numerous  minute  linear  bodies,  moniliform  in  structure, 
all  through  the  liquid,  and  which  in  many  instances  were  in  active  motion, 
making  the  whole  mass  of  the  liquid  alive  with  them,  the  fluid  being  still 
fresh  and  sweet.  These  are  the  so-called  "vibriones;"  they  have,  how- 
ever, no  connection  whatever  with  the  vibrii,  either  in  structure  or  mode 
of  development.  From  the  numerous  examinations  made,  connected  with 
diseased  tissues,  and  fermenting  and  decaying  bodies,  I  am  strongly  im- 
pressed with  the  belief  that  many  of  them  are  organisms,  allied  to  sperm 
cells,  being  spermatozoid  or  antherozoid  in  character.  There  is  evidence 
for  believing  some  of  them  to  be  embryonic  states  of  filamentous  organisms 
belonging,  or  closely  allied  to,  the  confervaceas.  These  latter  are  found  in 
their  mature  state  abundantly  in  the  spleen,  kidneys,  and  liver  of  animals  and 
of  the  human  subject,  wound  together  in  various  ways  and  firmly  attached 
to  the  glandular  vessels.  Analogous  bodies  are  found  in  all  stagnant  wa- 
ters, in  the  asci  of  Cryptogams,  in  the  pollen  grains  of  Pheenogams,  in 
the  secretions  and  blood  of  the  human  body  in  all  low  typhoid  types  of 
disease,  in  all  fermenting  bodies,  and  especially  during  the  incipient  stages 
of  active  putrefactive  fermentation  (decay)  in  animal  tissues.  By  inocu- 
lating fresh  meat  with  them  its  decay  is  accelerated.  During  that  stage 
of  decay  in  the  dead  human  body  when  dissecting  wounds  are  so  dangerous, 
they  are  very  abundant  and  active;  at  later  stages  of  the  decay,  when 
wounds  are  less  dangerous,  they  are  less  numerous,  and  either  motionless 
or  sluggish,  or  are  developed  into  inactive  filaments.  May  they  not  be  the 
source  of  the  dangerous  typhoid  conditions  produced  by  dissecting  wounds? 
Occasionally  was  met  a  cell  containing  the  sperm  cells  (so  called  vibriones) 
just  described.  Torula  cells  were  frequently  met  with,  either  single  or 
aggregated  in  masses.  There  were  also  several  asci  and  numerous  highly 
refractive  sporoid  bodies  noticed,  besides  a  peculiar  barbed  filament  that  I 
have  frequently  met  with,  connected  with  the  glands  and  circulating  fluids 
of  animals. 

Exp.  16.  Tears.- — Evaporated  to  dryness  forty  drops  of  freshly  secreted 
tears,  and  treated  the  residuum  for  determining  the  presence  of  cholesterine 
and  seroline.  The  tears  were  secreted  by  a  lady  of  middle  age,  of  remark- 
able health  and  vigour  of  constitution. 


294        Salisbury,  Cholesterine  and  Seroline  as  Secretions.  [April 


The  residuum  in  the  forty  drops  was  large.  On  allowing  the  final  alco- 
holic solution  to  evaporate  slowly  between  glass  slides,  a  fine  crop  of  cho- 
lesterine crystals  was  the  result.  They  resembled  much  the  crystals  in 
Fig.  16. 

Exp.  17.  Milk. — Milk  of  a  young  married  lady,  of  vigorous  constitu- 
tion, eight  months  gone  with  her  first  child.  Evaporated  one  drachm  to 
dryness  carefully  over  a  water  bath — within  a  few  minutes  after  it  was 
drawn — and  subjected  the  residuum  (which  was  large)  to  the  process  for 
determining  cholesterine  and  seroline.  The  final  hot  alcoholic  solution,  on 
evaporating  between  glass  slides,  yielded  a  large  crop  of  rhomboidal  and 
rectangular  plates  of  cholesterine — a  sample  of  which  is  seen  at  Fig.  11. 
No  crystals  of  seroline  were  discovered.  A  quantitative  analysis  was  not 
made;  but  the  qualitative  demonstrated  cholesterine  to  be  largely  present. 

Exp.  18.  Milk  from  a  lady  of  fine  constitution,  nursing  her  second  child, 
which  is  nine  months  old.  Milk  abundant,  and  child  healthy  and  robust. 
Took  500  grains  of  the  newly  secreted  milk  and  evaporated  it  to  dryness 
over  a  water  bath,  and  proceeded  with  the  residuum  (which  was  large)  to 
determine  the  presence  and  amount  of  cholesterine  and  seroline.  On  eva- 
porating the  final  alcoholic  extract  to  dryness  carefully  over  a  water  bath 
in  a  tarred  porcelain  capsule,  I  found  .64  of  a  grain  of  unsaponifiable  matter , 
which  proved  to  be  seroline  and  cholesterine.  From  the  apparent  relative 
proportion  of  the  crystals  exhibited  between  the  glass  slides,  I  should  esti- 
mate over  one-half  to  be  cholesterine. 

The  result  may  be  stated  as  follows : — 


Fearing  there  might  be  some  error  in  this  result  I  repeated  the  process — 
carrying  on  the  saponification  with  a  strong  solution  of  pure  caustic  potassa 
— at  a  temperature  of  212°  F.  over  a  water  bath,  for  one  and  a  half  hours, 
repeatedly  stirring;  then  largely  diluting  with  water  and  filtering,  &c. 
The  result  was  the  same  as  in  the  preceding  experiment.  A  concentrated 
hot  alcoholic  solution,  placed  between  glass  slides,  crystallized  in  long 
slender,  often  radiating  needles,  as  seen  in  Fig.  12.  Mixed  with  these 
crystals  of  seroline,  appeared  plates  of  cholesterine,  c,  d,  w,f.  These 
crystals  first  appeared  as  seen  at  c,  then  passed  into  the  forms  d,  d,  and 
these  into  the  forms  w;  and  Ub  into  the  forms  seen  at  ftf. 

Exp.  19.  Took  700  grains  of  healthy,  freshly  secreted  cow's  milk  (about 
five  months  after  coming  in),  evaporated  to  dryness  over  a  water  bath, 
and  treated  the  residuum  as  hereafter  described  for  obtaining  seroline  and 
cholesterine.  The  final  alcoholic  solution,  being  carefully  evaporated  and 
thoroughly  dried  over  a  water  bath,  in  a  tarred  porcelain  capsule — weighed 
.759  of  a  grain,  which  proved  to  be  seroline  and  cholesterine.  On  redissolving 
in  hot  alcohol  and  allowing  a  concentrated  solution  to  crystallize  between 
glass  slides,  the  seroline  crystals  were  found  to  resemble  those  from  the 
milk  of  the  human  subject  (Fig.  12).  Those  of  cholesterine  were  rather 
peculiar. 

The  result  of  the  analysis  may  be  stated  as  follows: — 

Fresh  cow's  milk   700  grains. 

Seroline  and  cholesterine  759  " 

Percentage  of  seroline  and  cholesterine        .       .       .1084  " 


Freshly  secreted  milk  .... 
Stercorine  and  cholesterine  . 
Percentage  of  stercorine  and  cholesterine 


500  grains. 
.64  " 
.128  " 


1863.]     Salisbury,  Cholesterine  and  Seroline  as  Secretions.      •  295 

The  last  portions  dissolved  from  the  dry  matter  Of  the  milk,  by  ether, 
contained  the  majority  of  the  cholesterine.  The  seroline  and  the  saponi- 
fiable  fats  were  the  first  to  be  dissolved.  For  this  reason,  two  ethereal 
extracts  were  made  from  the  dried  milk.  In  the  first,  the  dried  pulverized 
matter  was  digested  at  a  temperature  of  75°  to  80°  F.  for  twelve  hours, 
in  pure  ether,  frequently  stirring,  the  vessel  being  so  covered  as  to  prevent 
as  much  as  possible  the  evaporation  of  the  ether.  It  was  then  filtered, 
and  this  first  extract  proceeded  with  in  the  usual  way.  No  cholesterine 
was  detected  in  it ;  but  quite  a  large  percentage  of  seroline,  which  in  its 
crystals  resembled  that  of  the  human  milk  (Fig.  12).  The- dry  matter 
was  a  second  time  digested  in  ether,  frequently  stirring,  for  twenty-four 
hours;  then  filtered,  thoroughly  washing  with  warm  ether,  and  this  second 
extract  proceeded  with  as  with  the  first.  The  final  alcoholic  extract,  on 
being  evaporated  to  dryness  over  a  water  bath,  left  a  yellowish  matter 
having  something  the  appearance  and  consistence  of  unbleached  wax.  Its 
lustre,  however,  was  more  pearly.  It  was  but  slightly  soluble  in  cold  alco-, 
hoi ;  slowly  soluble  in  hot  alcohol,  and  readily  soluble  in  ether  both  cold 
and  warm.  The  concentrated  ethereal  solution,  on  being  placed  between 
glass  slides,  so  as  to  prevent  its  too  rapid  evaporation,  soon  crystallized 
into  beautiful  cholesterine  plates. 

There  were  a  few  acicular  prisms  or  plates,  bent  in  the  form  of  a  crescent. 
They  resembled  those  seen  at  d,  Fig.  8. 

Milk  holds  cholesterine  with  great  tenacity,  and  requires  long  digestion 
to  completely  separate  it.  The  early  secreted  milk  in  the  human  subject, 
previous  to  birth,  is  quite  free  from  seroline;  but  after  birth,  and  during 
nursing,  the  seroline  is  secreted  largely  with  the  cholesterine. 

Exp.  20.  Intermittent  fever.  Perspiration. — Sept.  10.  John  Laucla- 
bagh1  was  attacked  with  intermittent  fever.  Type  quotidian.  Had  been 
free  from  the  disease  for  eighteen  years  previous.  On  the  afternoon  of  the 
14th  (fifth  day  of  disease)  procured  about  one-half  ounce  of  the  perspira- 
tion, during  the  sweating  stage  of  the  paroxysm.  Perspiration  alkaline, 
limpid  like  water,  and  perfectly  clear  and  transparent.  Subjected  two 
drachms  to  the  process  for  obtaining  cholesterine  and  seroline.  Obtained 
a  beautiful  crop  of  crystals,  a  sample  of  which  is  seen  at  Fig.  4,  a  and  b. 
The  seroline  and  cholesterine  appeared  to  be  about  equally  divided.  The 
seroline  crystals  were  very  beautiful,  long,  slender  needles.  When  a  crystal 
was  alone,  so  that  the  whole  of  it  could  be  seen,  one  end  presented  the 
appearance  of  a  narrow  rectangular  plate,  while  the  other  tapered  off  into 
a  sharp  acicular  point.  Sometimes  the  bases  (large  ends)  of  the  crystals 
were  bifurcated,  and  at  others  the  apices  were  more  or  less  divided.  The 
cholesterine  crystallized  in  large  rhomboidal  and  rectangular  plates.  A 
quantitative  examination  was  not  made,  but  the  qualitative  determined 
these  bodies  to  be  largely  present  in  the  perspiration  of  intermittent  fever. 

Exp.  21. 2  Urine. — Charles  Whitney,  aged  five  years,  was  attacked  Sept. 
13,  with  intermittent  fever — quotidian  type.  Never  had  chills  and  fever 
before.  He  resides  in  the  3d  ward  near  and  but  a  few  feet  above  the  ague 
bogs.  At  11  A.  M.,  Sept.  13,  was  taken  with  the  first  well-marked  pa- 
roxysm.   The  sweating  stage  terminated  at  4  P.  M.    On  the  following 

1  This  case  was  reported  and  perspiration  furnished  by  Dr.  Effinger. 

2  I  am  indebted  to  the  kindness  of  Dr.  Effinger  for  the  reports  and  the  materials 
furnished  for  examination  of  the  cases  in  Experiments  21  to  33,  and  35  and  37. 


296        Salisbury,  Cholesterine  and  Seroline  as  Secretions.  [April 

day  (Sept.  14)  the  paroxysm  commenced  at  9  A.  M.  The  algid,  pyrexial 
and  sweating  stages  were  all  well-marked.  Voided  the  sample  of  urine — 
of  this  experiment — at  3  P.  M.,  as  the  febrile  stage  was  passing  off  and 
the  sweating  coming  on. 

Subjected  two  ounces  of  the  urine  to  the  process  for  obtaining  choleste- 
riue and  seroline.  Obtained  from  the  final  alcoholic  solution  a  large  crop 
of  beautiful  rhomboidal  and  rectangular  plates,  a  sample  of  which  is  seen 
at  Fig.  18.  Some  of  the  crystals  were  divided  at  the  extremities,  as  is  seen 
at  a. 

Exp.  22.  Mr.  C  ,  aged  48,  was  attacked  with  intermittent  fever, 

tertian  type,  Sept.  1.  Arrested  after  the  second  paroxysm.  Relapse  Sept. 
15.  Arrested  the  second  time  after  the  second  paroxysm.  Urine  obtained 
Sept.  21,  four  days  after  the  arrest  of  the  paroxysm  the  second  time.  His 
complexion  was  sallow,  appetite  poor,  with  considerable  physical  prostra- 
tion, and  mental  lethargy. 

His  residence  was  near  a  large  excavation  which  was  being  made  in  the 
low  ground  adjoining  the  canal,  and  from  which  he  was  constantly  exposed 
to  the  seeds  of  the  disease.    Never  had  the  disease  before. 

One  ounce  of  the  urine  was  subjected  to  the  process  for  determining 
the  presence  of  cholesterine  and  seroline.  Well-marked  rhomboidal  and 
rectangular  plates  of  cholesterine  were  obtained,  resembling  those  at  Fig. 
18.    No  seroline  found. 

Exp.  23.  James  Scott,  aged  13  years,  living  immediately  on  the  border 
of  the  ague  bogs,  at  Lancaster,  O.,  and  but  about  five  feet  above  them, 
had  been  labouring  under  intermittent  fever  most  of  the  time  since  the  1st 
of  August.  Type  quotidian.  Obtained  his  urine  Sept.  26,  during  the 
interval  between  the  paroxysms,  and  two  days  after  he  had  commenced 
taking  quinia  (previously  he  had  been  dosed  with  herb  teas).  Subjected 
one  ounce  of  the  urine  to  the  process  for  determining  the  presence  of  cho- 
lesterine and  seroline.  Obtained  a  few  small  well-marked  crystals  of  the 
former  body,  but  none  of  the  latter. 

Exp.  24.  Ellisworth  McLean,  aged  11  months,  was  attacked  with  inter- 
mittent fever  —  quotidian  type  —  during  the  forepart  of  August.  Dr. 
Effinger  saw  the  child  for  the  first  time  on  the  *7th  of  October.  He  reports 
him  as  much  reduced,  very  pale,  flesh  doughy  ;  face  bloated,  and  feet  and  legs 
oedematous.  Spleen  enlarged,  forming  a  well-marked  "  ague  cake."  He 
commenced  his  treatment  with  acetate  of  potash.  He  obtained  the  urine 
for  me  on  the  9th  of  October,  during  the  apyrexial  stage.  Urine  pale, 
clear,  and  slightly  alkaline.  Subjected  two  ounces  to  the  process  for  deter- 
mining the  presence  of  cholesterine.  Obtained  a  fine  crop  of  well-marked 
crystals,  resembling  those  at  Fig.  18. 

Exp.  25.  Urine  of  remittent  fever. — Mr.  C  ,  aged  about  30,  had 

been  labouring  for  some  days  under  an  attack  of  remittent  fever.  Obtained 
his  urine  on  the  ninth  day  of  the  disease,  when  convalescing.  Treated  two 
ounces  of  the  urine  for  cholesterine  and  seroline.  Obtained  a  fine  crop  of 
cholesterine  crystals,  with  which  were  mixed  a  few  crystals  of  seroline. 

Exp.  26.  Urine  of  typhoid  fever. — Mrs.  E  ,  a  married  lady  of 

about  30,  of  good  constitution,  was  attacked  with  typhoid  fever,  August 
20.  On  Sept.  9,  the  fourteenth  day  of  disease,  obtained  his  urine.  Urine 
acid,  high-coloured  ;  full  of  active  "  vibriones,"  and  had  a  large  deposit  of 


1863.]     Salisbury,  Cholesterine  and  Seroline  as  Secretions. 


297 


rhomboidal  and  lozenge-shaped  prisms  and  plates  of  lithic  acid.  Pulse 
from  100  to  120.  Considerable  enteric  tenderness,  with  slight  diarrhoea. 
Subjected  two  ounces  of  the  urine  to  the  process  for  determining  the  pre- 
sence of  cholesterine  and  seroline.  Obtained  a  large  crop  of  well-defined 
rhomboidal  and  rectangular  plates,  a  sample  of  which  is  seen  at  Fig.  16. 
The  crystals  were  formed  between  glass  slides,  and  were  very  large  and 
beautiful.    At  a  is  a  long  6-sided  prism,  made  up  of  distinct  laminae. 

Exp.  27.  Mrs.  E  •  (the  same  case  as  26),  on  the  18th  of  September 

and  the  twenty-second  day  of  the  disease,  appeared  to  be  improving.  The 
mind  was  clearer,  and  appetite  better ;  but  the  pulse  still  remained  up  to 
110  and  120,  and  was  small.  Skin  dry.  Strength  of  body  and  mind 
improved  since  Sept.  9th.  Obtained  her  urine.  It  was  lighter  in  colour 
and  contained  less  sediment  than  the  previous  one.  The  character  of  the 
sediment  was,  however,  the  same.  Subjected  two  ounces  to  the  usual  pro- 
cess for  obtaining  cholesterine.  Obtained  a  fine  crop  of  crystals  like  those 
at  Pig.  16. 

Exp.  28.  Mrs.  E  (same  case  as  26  and  27) — typhoid  fever — Oct. 

20,  fifty-fourth  day  of  disease.  Patient  still  in  a  very  low,  depressed  state. 
Pulse  120,  but  no  fever  ;  is  very  pale,  body  feeble,  mind  weak,  nervous,  and 
fretted  by  the  least  noise.  Hearing  completely  restored  and  very  sensitive. 
Has  scarcely  any  appetite,  sleep  nervous  and  disturbed.  Urinates  fre- 
quently and  quite  copiously.  Obtained  the  urine  Oct.  20,  through  the 
kindness  of  her  attending  physician,  Dr.  Effinger.  Urine  pale  (still  con- 
taining many  vibriones),  strongly  acid,  and  contains  much  less  sediment 
than  the  previous  samples. 

Subjected  two  ounces  to  the  process  for  determining  the  presence  of 
cholesterine  and  seroline.  Found  cholesterine  still  present,  in  considerable 
quantity  ;  quite  as  large  as  in  the  previous  examinations.  The  plates  had 
the  appearance  of  those  at  Fig.  16.    No  seroline  was  found. 

Exp.  29.  Libby  ,  domestic  at  Mrs.  E.'s,  aged  25,  down  with  typhoid 

fever.  Attended  Mrs.  E.  in  her  attack  of  typhoid  fever.  Libby  was 
attacked  ou  the  4th  of  October,  thirty-eight  days  after  Mrs.  E.  was  taken 
down.  Oct.  20,  the  seventeenth  day  of  the  disease,  obtained  her  urine 
through  Dr.  Effiinger,  her  attending  physician.  He  reports  the  diarrhoea 
constant,  and  the  most  annoying  symptom,  indicating  enteric  glandular 
depositions  and  inflammation.  For  the  last  week  the  passages  were  mixed 
with  blood.  Mind  yet  clear,  but  very  deaf;  has  been  so  for  over  a  week. 
Prostration  not  very  great,  less  than  ordinary.  Urine  slightly  acid,  high- 
coloured,  with  considerable  lithic  sediment. 

Subjected  two  ounces  of  the  urine  to  the  process  for  obtaining  choleste- 
rine and  seroline.  Obtained  a  fine  crop  of  crystals  of  cholesterine,  which 
resembled  those  seen  at  Fig.  16.    No  seroline  found.  * 

Exp.  30.  Libby  (same  case  as  the  above,  at  an  earlier  date),  Oct.  8, 
fourth  day  of  the  disease.  Obtained  urine,  and  subjected  it  to  the  process 
for  obtaining  cholesterine  and  seroline.  Obtained  well-defined  rhomboidal 
and  rectangular  plates  of  cholesterine.  The  amount  present  was  less  than 
in  the  urine  of  the  preceding  experiment.    No  seroline  found. 

Exp.  31.  Samuel  E  ,  aged  11  years,  son  of  Mrs.  E  ,  was  taken 

down  with  typhoid  fever  on  the  8th  of  October.  On  October  20th — the 
twelfth  day  of  the  disease — obtained  his  urine,  through  the  attending  phy- 


298        Salisbury,  Cholesteriue  and  Seroline  as  Secretions.  [April 


sician,  Dr.  Effinger.  He  reports  the  case  a  mild  type  of  the  disease.  He 
says,  "There  are  no  marked  symptoms  of  disturbance  of  the  system,  either 
functional  or  organic,  except  at  night,  when  he  is  restless  and  feverish. 
Though  an  active  and  sprightly  boy,  he  has  no  disposition  to  set  up  or 
leave  his  bed.  While  there  recumbent  he  is  cheerful  and  pleasant,  amusing 
himself  with  his  slate  and  books.  As  soon  as  he  gets  up  and  moves  about 
he  becomes  pale  and  sick,  and  goes  back  to  bed." 

Urine  strongly  acid,  of  a  yellowish  colour,  with  considerable  flocculent 
sediment.  The  upper  portion  of  the  precipitate  is  light  coloured,  and  the 
lower  of  the  colour  and  appearance  of  brick  dust.  This  lower  portion  is 
made  up  of  lithates.  Two  ounces  of  the  urine  were  subjected  to  the  pro- 
cess for  obtaining  cholesterine  and  seroline.  A  few  well-defined  rhomboidal 
and  lozenge-shaped  tablets  of  cholesterine  were  obtained.  The  cholesterine 
was  small  in  this  urine.    No  seroline. 

Exp.  32.  Lucy  ,  the  sister  and  nurse  of  Libby  (domestic  to  Mrs. 

E  ),  was  attacked  with  typhoid  fever  on  the  8th  of  November,  thirty- 
six  days  after  her  sister  Libby  was  attacked,  and  whom  she  attended  as 
nurse.  Obtained  her  urine,  through  the  attending  physician,  Dr.  Effinger, 
on  the  22d  day  of  November,  the  fourteenth  day  of  the  disease.  "Fever 
constant,  but  not  high.  Diarrhoea  set  in  on  the  20th  November  (day  before 
yesterday).  Discharges  frequent  and  bloody.  Urine  acid,  high  coloured, 
and  contains  a  large  precipitate  of  lithates. 

Two  ounces  of  the  urine  were  subjected  to  the  process  for  obtaining 
cholesterine  and  seroline.  A  fine  crop  of  cholesterine  crystals  was  ob- 
tained, the  appearance  of  which  were  like  those  in  Fig.  16.  Crystallized  on 
the  glass  slides  it  had  a  beautiful  pearly  lustre  to  the  naked  eye.  Choles- 
terine occurred  largely  in  this  sample  of  urine.    No  seroline  was  found. 

Exp.  33.  Urine  of  diphtheria. — Lizzie  Prentice,  aged  5  years,  labouring 
under  well-marked  diphtheria.  Morning  urine  obtained,  and  two  ounces 
subjected  to  the  process  for  obtaining  cholesterine  and  seroline.  Obtained 
a  few  well-marked  crystals  of  cholesterine.    No  seroline. 

Exp.  34.  Urine  of  varicella. — Sallie  Mattock,  aged  8  years,  labouring 
under  well-marked  varicella.  Her  morning  urine  was  obtained  when  the 
eruption  was  at  its  height.  Treated  two  ounces  of  it  for  cholesterine  and 
seroline.  Obtained  well-marked  crystals  of  cholesterine,  a  sample  of  which 
is  seen  at  Fig.  17.    No  seroline  found. 

Exp.  35.  Urine  of  jaundice. — Urine  of  a  patient  labouring  under  well- 
marked  jaundice.  Urine  voided  on  the  fifteenth  day  of  the  disease.  Urine 
slightly  acid,  high  coloured,  with  quite  a  large  flocculent  yellow  precipitate. 
Two  ounces  of  the  urine  were  evaporated  over  a  water-bath  to  dryness, 
and  the  residuum  treated  in  the  usual  way  for  cholesterine  and  seroline. 
The  final  alcoholic  extract,  on  being  placed  between  glass  slides  and  allowed 
to  stand  for  six  hours,  gave  a  fine  crop  of  crystals ;  some  of  which  repre- 
sent the  usual  crystalline  form  of  cholesterine.  The  crystals  were  small, 
but  quite  numerous.  Some  of  the  crystals  were  split  at  the  ends,  like  those 
at  a  and  b,  Fig.  3.  Others  were  very  acutely  rhomboidal ;  while  others 
were  acicular,  yet  retained  somewhat  the  very  acutely  rhomboidal  outline, 
where  they  were  perfect  and  alone.  These  last  were  undoubtedly  crystals 
of  seroline,  and  were  quite  abundant. 

Exp.  36.  Urine  from  a  lady  affected  with  jaundice.  Urine  voided  during 


1863.]     Salisbury,  Cholesterine  and  Seroline  as  Secretions.  299 

the  third  week  of  the  disease.  Had  a  high  colour,  strong  odour,  and  a  small, 
yellowish  sediment,  resembling  oil  globules.  Treated  in  the  usual  way — 
one  ounce  for  cholesterine  and  seroline.  Obtained  a  very  fine  crop  of  crys- 
tals, consisting  of  long  rhomboidal  and  rectangular  plates  of  cholesterine, 
with  which  were  mixed  a  few  acicular  crystals  of  seroline. 

Exp.  37.  Mrs.  M  ,  cook  on  board  a  canal  boat,  aged  53,  was  at- 
tacked with  jaundice  about  the  first  of  September,  and  is  still  labouring 
under  the  disease  (October  26th).  Obtained  urine,  through  her  attending 
physician,  Dr.  Effinger,  and  subjected  two  ounces  to  the  process  for  deter- 
mining the  presence  of  cholesterine  and  seroline.  The  final  alcoholic  solu- 
tion, evaporated  between  glass  slides,  afforded  a  fine  crop  of  cholesterine 
crystals,  showing  this  body  quite  largely  present. 

Exps.  38,  39,  and  40 — Butter,  and  beef  and  hog  suet — were  the  exami- 
nations of  butter,  and  beef  and  hog  suet.  Cholesterine  and  seroline  were 
demonstrated  in  all  of  them.  In  beef  suet,  cholesterine  occurs  quite  largely. 

Exp.  41.  Urine  of  diabetes  mellitus. — Mr.   *,  labouring  under  a 

severe  attack  of  diabetes.  The  patient  is  a  robust,  middle-aged  man,  who 
has,  previous  to  this  attack,  enjoyed  good  health.  He  passed  about  192 
ounces  of  urine  daily.  It  was  rich  in  sugar,  and  underwent  active  fermenta- 
tion ;  during  which  the  torula  (yeast)  cells  and  filaments  were  greatly  mul- 
tiplied. A  sample  of  the  urine  (J  pint),  the  next  day  after  it  was  voided, 
was  subjected  to  the  process  for  determining  the  presence  of  cholesterine 
and  seroline.  From  the  £  pint,  4.32  grains  of  cholesterine  were  obtained. 
The  crystals  were  very  large  and  beautiful,  a  sample  of  which  is  seen  at  Fig. 
15.  No  seroline  was  obtained.  From  this  experiment  it  is  seen  that  cho- 
lesterine occurs  largely  in  diabetic  urine.  The  discharge  of  a  single  day 
(192  ounces)  would  contain  103.68  grains  of  cholesterine.  The  discovery 
of  cholesterine,  as  a  secretion  of  the  kidneys  in  diabetes  metlitus,  may 
throw  some  additional  light  upon  the  nature  of  the  disease,  and  perhaps 
suggest  some  modifications  in  its  treatment. 

Exp.  42.  Healthy  urine. — Examined  8  ounces  of  healthy  urine  for  cho- 
lesterine and  seroline.  The  urine  was  voided  by  a  pregnant  lady,  of  fine 
constitution,  eight  months  gone  with  her  first  child.  Urine  slightly  acid. 
Was  unable  to  detect  the  least  trace  of  either  of  the  bodies  sought  for. 

Exp.  43. — Examined  the  urine  of  a  strong,  healthy  man,  aged  about 
30,  for  cholesterine  and  seroline.  Subjected  4  ounces  to  the  usual  process 
(the  one  used  in  the  preceding  experiments),  but  was  not  able  to  detect  a 
trace  of  either  of  the  bodies. 

Exp.  44.  Perspiration  in  health. — Examined  1  drachm  of  healthy  per- 
spiration (secretion  excited  by  vigorous  exercise)  for  cholesterine  and  sero- 
line.   Well-marked  crystals  of  cholesterine  were  found.    No  seroline. 

Exp.  45.  Ovarian  tumour. — The  following  note  from  Dr.  Effinger,  of 
Lancaster,  Ohio,  explains  the  subject  of  this  experiment : — 

"Dear  Doctor:  Yesterday  morning  I  made  a  post-mortem  of  Mrs.  Calvin 
Tripp,  who  died  of  ovarian  tumour.  The  tumour  weighed  62  pounds,  water  15 
lbs.,  and  hard  part  of  tumour  47  lbs.    I  made  a  few  slices  from  different  parts 


1  I  am  indebted  to  Dr.  Boerstler  for  reporting  this  case  and  furnishing  the  urine 
for  examination. 


300        Salisbury,  Cholesterine  and  Seroline  as  Secretions.  [April 

of  the  tumour,  which  I  send  you.  I  found  imbedded  in  the  substance  a  small, 
dead  worm  that  may  possibly  be  a  novelty.  You  will  find  it  in  the  cut  I  made 
near  its  burrow  cell. 

"  Eespectfully  yours, 

"M.  Effinger. 

"Lancaster,  Nov.  29th,  1862." 

The  tumour  had  a  white,  fatty  appearance,  to  the  unaided  eye.  It  was, 
however,  very  firm  and  tenacious.  The  microscope  demonstrated  it  to  be 
strictly  a  fibrous  tumour.  A  portion  of  it  was  examined  for  cholesterine 
and  seroline,  but  neither  of  them  were  detected. 

Fig.  13  represents  the  worm  referred  to  in  the  above  note  of  Dr.  Effinger. 
Length  two  lines ;  diameter  f  of  a  line.  To  the  naked  eye  it  had  the 
appearance  of  a  small  fragment  of  clotted  blood.  Viewed  with  a  \  inch 
objective,  it  appeared  the  size  seen  at  Fig.  13.  Colour  blood- red,  except 
the  sucker  and  around  the  margins  of  the  body.  When  emptied  of  its  food 
it  had  a  transparent  white  colour.  It  had  one  sucker,  and  that  on  the 
anterior  part  of  the  body.    It  appears  to  be  allied  to  the  genus  Festucaria. 

While  examining  a  thin  slice  of  the  tumour  under  the  microscope,  I  dis- 
covered among  the  fibres,  the  mite  represented  at  Fig.  14.  Length  of 
an  inch.  A  short  time  since,  while  examining  the  perspiration  from  a 
patient  labouring  under  intermittent  fever,  I  found  a  different  species  of  the 
same  genus. 

Chemical  Properties  of  Cholesterine. — The  sample  of  cholesterine,  ob- 
tained from  the  second  ethereal  extract  from  milk,  remained  unfused  at  a 
heat  considerably  above  that  of  boiling  water.  Its  precise  freezing  point 
was  not  determined.  The  freezing  point  of  cholesterine  is  stated  by  dif- 
ferent authorities  at  2? 9°  and  293°  F. 

Concentrated  S03  strikes  a  beautiful  purple  red  colour,  with  the  choles- 
terine obtained  in  the  foregoing  experiments.  In  order  to  see  this  test  to 
advantage,  a  little  cholesterine  should  be  spread  thinly  on  a  glass  slide  or 
plate,  and  a  drop  of  concentrated  S03  placed  on  and  spread  over  it  by 
means  of  a  glass  rod.  The  beautiful  purple  red  tint  will  begin  to  show 
itself — first,  around  the  edges  of  the  acid,  and,  in  a  few  minutes,  the  whole 
surface  will  assume  this  beautiful  colour.  Heat  should  not  be  applied,  nor 
too  much  acid  used. 

Cholesterine  is  soluble  in  9  parts  of  boiling  alcohol  of  0.84,  and  5.55 
parts  of  0.816.  It  is  soluble  in  12  parts  of  ether  at  32°  F.,  3.7  at  59°  F., 
and  2.2  at  boiling.  It  is  also  soluble  in  wood-spirit,  slightly  soluble  in 
boiling  oil  of  turpentine  and  in  water  containing  4  parts  of  dry  soap. 
Heated  with  S03  it  decomposes,  and  N05  changes  it  into  cholesteric  acid 
and  artificial  tannin.    Form.  C3sH330,  or  C3GH320. 

Chemical  Properties  of  Seroline. — Lehman  gives  the  melting  point  of 
seroline  at  98°  8'  F.    Boudet  at  97°  F. 

Boudet's  process  for  obtaining  seroline  from  the  blood — was  to  evapo- 
rate the  blood  to  dryness,  treat  the  residuum  thoroughly  with  water,  then 
dry  completely  the  residuum,  and  repeatedly  treat  it  with  boiling  alcohol. 


1863.]     Salisbury,  Cholesterine  and  Seroline  as  Secretions.  301 

This  alcoholic  extract  on  cooling;  let  fall  the  seroline  in  flocks.  By  this 
process  Boudet  must  have  obtained  with  the  seroline  some  small  portions 
of  margarine  and  stearine,  which  would  have  a  tendency  to  elevate  the 
melting  point. 

For  obtaining  the  seroline,  which  was  used  for  determining  the  fusing 
point  of  this  body,  I  evaporated  to  dryness  over  a  water  bath,  pulverized 
in  an  agate  mortar  and  digested  with  pure  ether  for  twelve  hours — re- 
peatedly stirring  and  keeping  the  vessel  so  covered  as  to  prevent  the  evapo- 
ration of  the  ether — filtered,  evaporated  filtrate  to  dryness  over  a  water 
bath,  and  digested  the  residue  at  212°  with  a  strong  solution  of  pure 
caustic  potassa  for  one  and  a  half  hours  to  saponify  the  saponifiable  fats ; 
then  largely  diluted  with  water  and  filtered,  washing  the  filter  with  water 
till  the  fluid  came  through  neutral.  The  filter  was  then  thoroughly,  yet 
carefully  dried  over  a  water  bath,  placed  in  a  warm  covered  funnel  and  kept 
filled  with  ether  till  that  which  passed  through,  on  evaporation,  left  no 
residuum.  The  filtrate  was  then  evaporated  to  dryness  over  a  water  bath 
and  redissolved  in  hot  absolute  alcohol,  and  the  seroline  allowed  to  deposit 
as  the  alcohol  cooled  and  evaporated  spontaneously.  Before  the  seroline 
was  tested  for  the  fusing  point,  it  was  exposed  to  the  heat  of  212°  over  a 
water  bath  in  a  watch  glass,  until  completely  deprived  of  all  alcohol  and 
moisture.  It  was  then  allowed  to  cool  and  crystallize  at  a  temperature  of 
50°  F.    When  perfectly  crystallized,  its  fusing  point  was  determined. 

The  seroline  thus  obtained  began  to  lose  its  white  colour  and,  crystalline 
structure  at  90°  F.  At  94°  F.  it  had  the  consistence  of  Canada  balsam 
and  had  lost  entirely  its  crystalline  structure,  and  at  96°  F.  it  flowed  readily, 
and  was  about  the  consistence  of  sweet  oil.  At  this  last  temperature  it 
had  a  light  straw  yellow  tinge.  At  32°  F.  it  had  a  white  pearly  lustre, 
like  spermaceti,  but  less  consistent.  At  50°  F.  it  had  the  consistence  of 
lard  at  80°.  When  allowed  to  crystallize  slowly,  it  crystallized  in  long- 
slender  needles,  as  seen  at  Figs.  12  and  4.  Cold,  it  was  odourless;  at  212° 
it  exhaled  a  sweet  oily  odour.  Almost  insoluble  in  cold  alcohol,  but  very 
soluble  in  ether  and  hot  alcohol.  Strikes,  like  cholesterine,  a  beautiful 
violet  red  colour  with  strong  S03. 

Primary  Form  of  the  Crystals  of  Cholesterine  and  Seroline. — The 
primary  form  of  the  crystals  of  cholesterine  appears  to  be  the  cube  and 
rhombic  prism.  In  a  few  instances,  in  the  early  stages  of  the  crystalliza- 
tion, hexagonal  prisms  were  noticed;  but  these  were  probably  formed  from 
the  rhombic  prisms  by  the  truncation  of  the  acute  angles,  as  is  the  case  in 
some  crystals  of  mica.  The  octohedra,  rectangular  prisms  and  plates  may 
be  secondary  forms  of  the  cube  and  rhombic  prism. 

In  these  experiments  there  has  appeared  some  evidence  in  favour  of  the 
very  acute  rhombic  and  rhomboidal  prisms  being  the  primary  form  of  the 
acicular  crystals  of  seroline. 


302        Salisbury,  Cholesterine  and  Seroline  as  Secretions.  [April 

Resume. — The  following  is  a  brief  summary  of  the  facts  indicated  by  the 
preceding  experiments : — 

1.  Cholesterine  occurs  largely  in  the  ova  of  the  human  subject  and  of 
animals. 

2.  In  the  seminal  fluid  of  the  human  subject,  seroline  and  cholesterine 
are  largely  present,  the  former  more  so  than  the  latter. 

3.  Cholesterine  occurs  very  largely  as  a  secretion  in  the  saliva.  No 
seroline  is  found. 

4.  Neither  seroline  nor  cholesterine  occurs  in  healthy  urine. 

5.  Cholesterine  occurs  quite  largely,  and  seroline  in  small  quantity  in 
jaundice-urine.  (These  bodies  are  probably  always  secreted  by  the  kidneys 
whenever  the  liver,  through  organic  or  functional  derangements — is  un- 
able to  secrete  them  from  the  blood.) 

6.  Cholesterine  and  colourless  blood  disks  are  secreted  or  effused  from 
highly  congested  and  inflamed  mucous  surfaces. 

7.  Cholesterine  is  secreted  or  effused  from  the  peritoneal  (serous)  mem- 
brane in  ascites. 

8.  Cholesterine  occurs  largely  in  the  fluid  of  spina  bifida  tumours. 

9.  Cholesterine  is  secreted  by  the  tear  glands. 

10.  Human  milk,  previous  to  birth,  is  rich  in  cholesterine.  No  sero- 
line detected  in  the  experiment  made. 

11.  After  the  birth  of  the  child,  and  during  nursing,  the  mammary 
glands  secrete  largely  cholesterine  and  seroline. 

12.  The  milk  of  the  cow  is  rich  in  cholesterine  and  seroline. 

13.  Butter,  beef,  and  hog  suet  contain  cholesterine  and  seroline. 

14.  The  primary  forms  of  the  crystals  of  cholesterine  appear  to  be  the 
cube  and  rhombic  prism ;  and  that  of  seroline,  the  very  acute  rhombic  or 
rhomboidal  prism ;  though  usually  appearing  as  simply  acicular. 

15.  Cholesterine  and  seroline  are  largely  secreted  from  the  blood  by  the 
sudorific  glands  during  the  sweating  stage  of  intermittent  fever.  These 
glands  become  important  blood  depurative  organs  in  this  disease. 

16.  The  kidneys  largely  secrete  cholesterine  in  intermittent  fever. 

17.  The  kidneys  secrete  cholesterine  in  varicella. 

18.  The  kidneys  secrete  cholesterine  in  diphtheritic  conditions. 

19.  The  kidneys  largely  secrete  cholesterine  in  the  disease  known  as 
diabetes  mellitus. 

20.  The  kidneys  secrete  cholesterine  and  seroline  in  remittent  fever. 

21.  The  kidneys  largely  secrete  cholesterine  in  typhoid  fever. 

22.  Cholesterine  is  secreted  by  the  sudorific  glands  in  health. 

Concluding  Remarks. — Cholesterine  appears  to  be  essentially  a  body, 
secreted  from  the  blood  by  the  glands  concerned  in  digestion ;  the  sudorific 
glands;  those  secreting  tears  and  milk;  and  by  the  testis  of  the  male  and 
ovary  of  the  female,  and  by  the  kidneys  in  hepatic  disease.    In  the  secre- 


1863.]     Salisbury,  Cholesterine  and  Seroline  as  Secretions.  303 

tions  of  the  testis  (seminal  fluid),  seroline  occurs  more  largely  than  choles- 
terine. In  the  female  ova,  cholesterine  occurs  largely,  and  no  doubt  has 
some  office  to  perform  in  furnishing  one  important  constituent  of  nourish- 
ment in  the  early  foetal  development ;  before,  in  viviparous  animals,  there 
are  any  uterine  attachments ;  and  in  oviparous,  before  they  escape  from 
the  ovarian  envelopes.  Mucous  and  serous  surfaces  do  not  appear  to  have 
any  power  to  separate  cholesterine  from  the  blood;  unless  perhaps  when 
under  the  influence  of  congestion  and  inflammation. 

As  cholesterine  occurs  so  largely  in  the  bile  and  saliva,  two  secretions 
important  in  digestion,  in  the  female  ova,  and  in  the  mother's  milk  upon 
which  the  young  feed,  is  it  not  highly  probable  that  it  has  some  important 
function  to  perform  in  digestion,  at  all  ages;  and  as  nourishment  and  a 
soporific  in  infancy,  it  only  becoming  excrementitious  proper  when  this 
office  is  ended,  and  it  is  changed  into  seroline  (stercorine  of  Dr.  Flint)  ? 

It  is  believed  to  be  pretty  well  established,  that  the  true  source  of  cho- 
lesterine is  the  nervous  system,  of  which  it  is  an  effete  product.  From  the 
nervous  system  it  passes  to  the  blood,  and  is  removed  from  the  blood  by 
the  liver. 

These  experiments  go  to  show  that  the  liver  is  not  the  only  organ  which 
separates  this  body  from  the  blood.  The  salivary,  tear,  mammary,  and 
sudorific  glands ;  and  the  testis  and  the  ovary  come  in,  each  in  its  peculiar 
time  and  place,  as  important  aids.  They  also  show  that  a  portion  of  the 
cholesterine  of  the  human  body  may  be  taken  into  it  through  the  food 
eaten,  consisting  of  milk  and  butter,  eggs,  beef,  and  hog  fat,  and  as  there 
are  more  or  less  blood  and  serous  matter  in  meat,  be  taken  in  in  that 
substance  also.  Still,  these  facts  do  not  argue  against  the  nervous  system 
being  its  true  original  source.  They  only  show  that  it  is  formed  in  the 
nervous  system  of  animals  as  well  as  in  that  of  the  human  subject ;  and 
that  in  feeding  upon  animal  food,  the  vascular  system  may  gather  this 
substance  from  two  sources,  the  nervous  system  and  the  food  eaten.  The 
nervous  system  being  the  source  of  cholesterine,  and  the  tear  glands  secret- 
ing this  body,  may  explain  why  the  profuse  shedding  of  tears,  in  health, 
for  any  great  length  of  time,  so  enervates  both  physically  and  mentally. 

All  functional  and  organic  derangements  of  the  liver  produce  despond- 
ency. The  dark  side  of  the  picture  is  the  one  ever  prominent.  Actions 
and  remarks  are  perverted,  and  everything  goes  wrong.  There  is  a  tend- 
ency for  this  condition  to  relieve  itself,  especially  in  the  female  sex,  by  a 
profuse  flow  of  tears.  May  not  this  peculiar  mental  and  moral  condition, 
full  of  sad  forebodings,  be  but  a  part  of  that  beautiful  sympathy  of  action 
between  different  organs  of  the  body,  wisely  designed,  in  this  instance,  to 
stimulate  the  tear  glands  to  excited  action,  in  order  that  they  may  perform, 
to  some  extent,  the  depurative  office  of  a  liver,  and  thus  relieve,  partially^ 
a  vascular  system  surcharged  with  cholesterine  ? 

That  weeping  relieves  sad  and  despondent  conditions  is  so  true  that  you 


304        Salisbury,  Cholesterine  and  Seroline  as  Secretions.  [April 


everywhere  find  it  proverbial ;  it  is  well  known  that  sudden  grief  does  much 
towards  deranging  the  functions  of  the  liver.  The  tear  glands,  through 
sympathy,  appear  to  come  in  as  little  safety-valves  to  the  vascular  system 
on  such  occasions,  as  well  as  on  others  hereafter  mentioned,  where  the  liver 
is  deranged  in  its  functions. 

In  climates  where  there  is  a  disposition  to  " biliousness"  ("bilious  cli- 
mates"), there  is  a  tendency  to  inaction  of  body  and  mind;  a  heavy  lethar- 
gic feeling  prevails ;  a  greater  tendency  to  lounge  about  lazily  and  to  sleep 
than  in  less  "bilious"  localities;  the  intellect  is  inactive  and  heavy;  there 
is  also  a  tendency  to  the  greater  deposition  of  adeps — a  tendency  to  obesity. 

In  all  diseased  conditions  of  the  liver  where  its  normal  functions  are 
impaired,  there  is  great  dulness  and  lethargy,  with  a  feeling  of  melancholy 
sadness  and  a  disposition  often  to  doze  and  sleep. 

Children  while  nursing  sleep  a  great  portion  of  the  time;  they  fall  asleep 
while  feeding:  there  is  also  a  remarkable  tendency  to  take  on  fat.  After 
being  weaned  they  are  much  more  wakeful,  and  the  fatty  deposits  usually 
decrease. 

The  free  use  of  cows'  milk  as  food  produces  heaviness  and  a  tendency  to 
sleep.  The  use  of  eggs  largely  as  food  produces  a  similar  lethargic  con- 
dition. 

May  we  not  account  for  the  lethargic  influence  and  the  tendency  to  sleep 
and  obesity  of  "bilious  climates,"  on  the  ground  of  the  blood  and  nervous 
system  becoming  and  remaining  constantly  surcharged  with  cholesterine? 
In  diseased  conditions  of  the  liver,  when  its  depurative  functions  are  im- 
paired, we  know  the  blood  and  nervous  system  become  surcharged  with 
this  body,  and  we  know  that  this  surcharged  condition  produces  results 
similar  to  those  of  "bilious  climates." 

May  not  the  cholesterine  and  seroline  in  the  food  of  nursing  infants  be 
one  cause  of  their  disposition  to  sleep  and  to  become  fat  ? 

May  not  these  bodies  also,  in  milk  and  eggs,  be  the  cause  of  their  pro- 
ducing heaviness  and  sleep?  When  using  milk  and  eggs  as  food,  the  liver 
has  to  perform  the  double  office  of  removing  the  cholesterine  formed  by  the 
nervous  system  and  that  taken  into  the  blood  by  the  food  eaten.  The 
result  is  that  the  blood  and  nervous  system  become  surcharged  with  this 
body,  and  we  have  temporarily  the  same  condition  of  the  system  that  occurs 
in  "  bilious  climates."  The  liver  being  more  or  less  deranged  in  its  func- 
tions in  intermittent  fever,  the  sudorific  glands  come  in  as  Wood  depurative 
aids  in  freeing  the  vascular  system  of  cholesterine  and  seroline  and  other 
effete  matters.  This  may  explain,  to  some  extent,  the  advantage  derived 
from  the  free  use  of  diaphoretics  as  aids  in  the  successful  treatment  and 
eradication  of  this  disease. 

The  secretion  of  cholesterine  from  the  blood  by  the  kidneys,  in  intermit- 
tent fever,  may  explain  why  it  is  that  the  free  use  of  diuretics  (acetate  of 
potash,  &c.)  are  so  beneficial  often  in  its  treatment.    Without  the  free  use 


1863.]     Salisbury,  Cholesterine  and  Seroline  as  Secretions.  305 

of  diaphoretics  and  diuretics  in  the  treatment  of  intermittent  fever  the  dis- 
ease is  seldom  so  perfectly  eradicated  from  the  system  as  to  prevent  its 
reappearance  the  following  spring;  while  with  their  proper  use,  the  disease 
seldom  reappears  unless  the  system  is  again  exposed  for  some  length  of 
time  to  the  exciting  cause. 

The  discovery  of  the  fact  that  the  kidneys  secrete  cholesterine  largely  in 
diabetes  mellitus  may  throw  some  light  upon  the  pathobgy  and  therapeu- 
tics of  this  peculiar  disease. 

Beady  process  for  detecting  the  presence  of  cholesterine  and  seroline. — 
As  the  ordinary  process  for  determining  the  presence  of  cholesterine  and 
seroline  is  too  lengthy  and  often  beyond  the  facilities  of  the  practising 
physician,  I  here  give  a  simple  method,  which  may  answer  as  a  -very  good 
approximate  means  (till  a  better  is  suggested)  for  detecting  these  bodies  in 
urine  and  other  secretions,  and  which  may  often  be  used  with  advantage  by 
physicians  in  their  practice  as  a  diagnostic  aid.  Care  should  be  taken,  in 
the  microscopic  examination  of  crystals  obtained  from  the  secretions  by 
this  process,  to  not  confound  those  of  cholesterine  with  those  of  lithic  acid 
and  chloride  of  sodium.  As  the  secretion  of  these  bodies  by  the  kidneys 
is  an  abnormal  function,  one  which  they  only  perform  when  the  liver,  whose 
normal  office  is  to  secrete  these  bodies,  is  deranged,  their  presence  in  the 
urine  will  usually  indicate  hepatic  derangement. 

Place  two  to  four  ounces  of  urine  in  a  six  ounce  bottle,  and  add  one 
ounce  of  pure  ether ;  tightly  cork,  and  agitate  by  turning  quickly  the  bot- 
tle on  different  ends,  allowing  the  ether  to  pass  backward  and  forward 
through  the  urine,  so  as  to  wash  it  completely — two  to  five  minutes'  stir- 
ring are  usually  sufficient ; — then  allow  the  ether  to  rise  to  the  surface,  and 
decant  into  a  clean  porcelain  or  glass  dish  and  evaporate  carefully  to  about 
ten  drops,  which  place  between  glass  slides  and  set  aside  for  several  hours 
to  crystallize.  When  this  is  completed,  a  microscopic  examination  with  a 
moderate  power  will  detect  the  cholesterine  plates  and  acicular  crystals  of 
seroline,  if  present. 

In  concluding,  I  take  pleasure  in  expressing  my  obligations  to  Drs. 
Boerstler  and  Effinger,  of  Lancaster,  Ohio,  for  valuable  aid.  They  have 
felt  a  lively  interest  in  these  experiments,  and  have  done  me  many  favours 
in  reporting  well-marked  cases  of  disease  and  in  furnishing  specimens  for 
examination. 


No.  XC.— April  1863.  20 


306  Flint,  Clinical  Report  on  Hydro-Peritoneum.  [April 


Art.  II. —  Clinical  Report  on  Hydro-Peritoneum,  based  on  an  analysis 
of  forty-six  cases.  By  Austin  Flint,  M.  D.,  Prof,  of  the  Principles 
and  Practice  of  Medicine  in  the  Bellevue  Hospital  Medical  College,  N. 
Y.,  and  in  the  Long  Island  College  Hospital. 

The  term  hydro-peritoneum  is  applicable  only  to  a  purely  dropsical  or 
serous  effusion  into  the  peritoneal  sac.  The  term  ascites  should  perhaps 
be  used  in  the  same  restricted  sense,  but  writers  are  accustomed  to  apply 
this  term  to  an  inflammatory,  as  well  as  a  dropsical,  effusion.  The  two 
forms  of  effusion  being  pathologically  distinct,  they  should  be  studied 
separately,  and  I  shall  limit  myself  in  this  article  to  the  latter  form ;  that 
is,  to  the  non-inflammatory  or  dropsical  effusion.  Excluding  cases  in  which 
liquid  (serum  and  lymph)  accumulates  in  the  peritoneal  sac  as  a  result  of 
peritonitis,  most  of  the  cases  in  which  effusion  accompanies  carcinomatous 
deposit  will  also  be  excluded,  the  effusion  in  these  cases  being  generally  due 
to  superadded  peritoneal  inflammation.  Hydro-peritoneum  occurs  in  con- 
nection with  anasarca  dependent,  generally,  on  either  renal  or  cardiac  dis- 
ease, or  on  the  two  combined.  I  shall  exclude  the'consideration  of  cases 
in  which  peritoneal  is  only  an  element  of  general  dropsy,  and  confine  my- 
self to  hydro-peritoneum  considered  as  a  local  affection. 

The  clinical  study  of  hydro-peritoneum  offers  several  interesting  ques- 
tions. The  first  point  to  which  attention  will  be  directed  is  the  causation 
of  the  affection.  The  affection  is  secondary,  and  dependent,  as  is  well 
known,  in  a  large  majority  of  cases,  on  disease  of  the  liver.  Questions  of 
interest  have  reference  to  its  connection  with  hepatic  and  other  morbid 
conditions,  and  also  to  remote  causes  co-operating  with  the  conditions  on 
which  the  dropsy  is  immediately  dependent.  Other  points  of  inquiry  relate 
to  the  symptomatology  of  the  affection,  to  its  progress  and  termination, 
the  prognosis,  and  the  management.  I  shall  consider  the  subject  so  far, 
and  so  far  only,  as  the  questions  embraced  in  its  clinical  study  may  be 
elucidated  by  the  facts  contained  in  the  recorded  histories  of  forty-six  cases. 

I  have  recorded  these  cases  during  the  last  thirteen  years.  A  very  large 
proportion,  viz.,  37,  were  observed  in  hospital  practice;  2  cases  were  in 
dispensary,  and  1  in  private  practice.  They  were  observed  in  different 
places,  as  follows:  10  cases  in  Buffalo,  N.  Y. ;  5  cases  in  Louisville,  Ky. ; 

II  cases  in  New  Orleans,  La.,  and  20  cases  in  the  cities  of  New  York  and 
Brooklyn.  Some  of  the  histories  are  incomplete,  the  patients  having 
passed  from  my  observation  prior  to  the  termination  of  the  affection.  The 
histories  vary,  also,  as  regards  completeness  in  details  while  the  cases  were 
under  my  observation.  Such  as  they  are,  I  shall  analyze  them  and  give 
the  results  in  treating  of  the  different  branches  of  the  subject.  In  a  con- 
siderable proportion  (24)  of  the  cases  a  fatal  termination  either  occurred 
while  the  patients  were  under  my  observation,  or  the  death  of  the  patient 


1863.]         Flint,  Clinical  Report  on  Hydro-Peritoneum.  307 

was  ascertained.  A  certain  proportion  of  the  remaining  22  cases  doubtless 
ended  fatally  after  the  patients  had  passed  from  my  observation.  But  for 
convenience  of  reference  I  shall  include  the  latter  under  the  head  of  non- 
fatal cases.  The  prognosis  will  be  one  of  the  topics  for  consideration,  and 
it  will  be  seen  in  that  connection  that  the  instances  in  which  a  permanent 
recovery  was  known  to  take  place  are  very  few. 

Causation  of  Hydro-Peritoneum. — The  causation  embraces,  as  just 
stated,  the  proximate  morbid  conditions  giving  rise  to  the  dropsy,  and  the 
remote  causes  producing  the  morbid  conditions  on  which  the  dropsy  imme- 
diately depends,  and,  also,  accessory  causes.  The  proximate  morbid  con- 
ditions are  to  be  ascertained  mainly  by  examinations  after  death.  What 
are  the  changes  found  in  fatal  cases  which,  from  their  constancy  and  cha- 
racter, may  be  considered  as  standing  in  an  immediate  causative  relation  to 
the  dropsical  effusion  ?  With  reference  to  this  question  I  will  proceed  to 
interrogate  the  fatal  cases  in  my  collection  in  which  post-mortem  examina- 
tions were  made. 

Examinations  after  death  were  made  in  14  cases.  In  each  of  these  cases 
the  liver  presented  morbid  changes.  This  organ  was  reduced  in  volume  in 
13  of  these  cases;  its  volume  was  increased  in  one  case  only.  The  degree 
of  reduction  varied,  being  in  some  cases  moderate,  in  other  cases  consider- 
able, and  in  one  case  very  great.  The  weight  in  all  but  two  of  the  cases 
in  which  the  organ  was  weighed,  was  diminished  below  the  limit  of  the 
variations  of  health.  It  was  weighed  in  10  cases.  In  one  the  weight  was 
3  lbs.  9  oz.,  which  is  not  perhaps  sufficiently  below  the  normal  average  to 
be  considered  as  necessarily  abnormal.  In  the  remaining  9  cases,  the 
weight  varied  from  2  lbs.  to  3 J  lbs.  The  organ  was  not  weighed  in  the 
case  in  which  the  reduction  in  volume,  and,  probably,  also  in  weight,  was 
greatest.  The  gross  appearances,  aside  from  the  volume,  differed  consider- 
ably in  different  cases.  In  8  cases  the  organ  was  not  altered  notably  in 
form,  and  the  external  surface  was  everywhere  smooth.  In  1  case  the 
deformity  was  great  although  the  surface  was.  smooth.  In  5  cases  the 
surface  was  nodulated  and  the  form  more  or  less  altered.  In  one  case  the 
deformation  was  so  great  that  the  organ  would  not  have  been  recognized. 
Of  this  case  I  shall  give  an  account  presently.  The  external  appearances 
iu  the  other  four  cases  are  thus  described : — 

Case  1.  "  Surface  irregularly  nodulated,  the  projecting  portions  varying 
in  size  from  that  of  a  pea  to  a  filbert,  and  of  a  dark  greenish  colour." 

Case  2.  "  Whole  surface  studded  with  nodules  varying  in  size,  present- 
ing a  hob-nail  appearance,  the  nodulated  portions  parenchymatous  and  the 
intervening  spaces  fibroid." 

Case  3.  "  Surface  irregular." 

Case  4.  "  Liver  studded  with  hob-nail  eminences." 

In  one  case  a  little  lymph  was  observed  on  the  convex  surface  of  the 


308 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


[April 


organ.  The  appearance,  on  section,  of  the  cut  surfaces,  is  described  in 
several  cases  as  granular.  In  one  case  the  nutmeg  appearance  was  marked. 
In  one  case  it  is  noted  that  the  "  cut  surfaces  presented  irregularly  shaped 
portions  of  variable  size  and  of  a  dark  green  colour,  with  white  hard  spots 
and  white  lines  irregularly  disposed."  The  granular  portions  were  in  some 
cases  yellow.  It  is  noted  in  one  case  that  "on  section  the  surfaces  present 
an  appearance  as  if  studded  with  yellow  granules  of  the  size  of  pins' 
heads."  In  one  of  the  cases  the  cut  surfaces  had  a  mahogany  colour,  the 
lobules  not  being  distinctly  visible.  The  two  orders  of  venous  radicles,  viz., 
the  intra-lobular  and  the  inter-lobular,  were  sometimes  visible  and  some- 
times not  apparent.  The  condition  as  regards  the  amount  of  blood  con- 
tained in  it  varied.  Generally  but  little  blood  or  serum  flowed  when  inci- 
sions were  made  ;  the  organ  appeared  to  be  dry  and  anaemic.  But  in  one 
case  there  existed  marked  congestion,  blood  flowing  freely  from  the  cut 
surfaces.  In  most  cases  it  is  noted  that  the  organ  was  unusually  dense  and 
resisting.  As  an  exception  to  this  rule  in  one  case  it  is  noted  as  soft  and 
flabby.  The  microscopical  appearances  are  noted  in  a  few  of  the  cases. 
In  one  of  these  the  "liver  cells  were  small,  wasted,  irregular  in  shape,  and 
filled  with  granular  matter."  In  another  case  the  "liver  cells  contained 
oil  drops  and  granular  matter."  In  two  cases  "the  liver  cells  contained 
oil  drops  in  abundance."  In  one  of  these  cases  the  nutmeg  appearance 
was  marked.  In  another  case  the  "  liver  cells  were  reduced  in  size,  con- 
taining some  oil  drops  and  granular  matter."  In  the  case  in  which  the 
liver  was  enlarged,  the  liver  cells  were  filled  with  oil,  and  the  field  of  the 
microscope  was  crowded  with  oil  drops  of  different  sizes.  The  records  are 
defective  as  regards  the  presence  of  fibrous  tissue  in  the  interlobular  spaces. 
Adhesions  to  adjacent  organs  are  noted  in  two  cases,  and  in  one  of  these 
the  organ  was  excessively  contracted  and  deformed.  In  both  cases  the 
surface  was  universally  adherent  to  the  surrounding  parts. 

These  results  go  to  show  the  constancy  with  which,  in  fatal  cases  of 
hydro-peritoneum  the  affection  is  associated  with  disease  of  the  liver.  They 
show  the  frequency  of  contraction  of  this  organ.  They  show  that  the 
external  surface  in  a  certain  proportion  of  cases  is  nodulated,  but  that  it 
is  oftener  smooth ;  that  the  cut  surfaces  generally  present  a  granular  ap- 
pearance ;  that  the  colour  varies,  being  either  yellowish,  greenish,  or  of  a 
dark  brown  mahogany  colour :  that  the  two  kinds  of  venous  radicles  may 
be,  or  may  not  be  apparent ;  that  the  nutmeg  appearance  is  sometimes 
marked ;  that  the  organ  is  usually  dense  and  resisting,  but  may  be  soft  and 
flabby ;  that  it  is  generally  anaemic,  but  may  be  congested,  and  that  it  is 
sometimes  morbidly  adherent  to  adjacent  parts.  Notwithstanding  these 
variations  in  the  gross  appearances,  the  essential  morbid  change  in  all  the 
cases  would  be  considered  as  embraced  by  the  term  cirrhosis.  This  term, 
first  employed  by  Laennec  when  the  minute  anatomy  of  the  liver  was  very 
imperfectly  understood,  denotes  an  appearance  by  no  means  uniformly  pre- 


1863.] 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


309 


sent,  viz.,  a  yellow  colour  resembling  that  of  impure  beeswax.  Laennec 
considered  the  appearance  of  yellow  granules  as  due  to  a  peculiar  morbid 
product,  bearing  an  analogy  to  the  tuberculous  deposit;  other  pathologists, 
regarding  the  liver  as  consisting  of  red  and  yellow  anatomical  elements, 
attributed  the  change  to  an  hypertrophy  of  the  latter.  These  ideas  have 
been  abandoned,  and,  now  that  the  normal  structure  of  the  organ  has  been 
in  a  great  measure  elucidated  by  the  researches  of  Kiernan  and  others, 
much  light  appears  to  have  been  shed  on  the  morbid  condition  in  cirrhosis, 
and  the  rationale  of  the  peritoneal  dropsy  dependent  thereon.  What  is 
the  essential  morbid  condition  in  cases  of  so-called  cirrhosis  ?  I  will  devote 
a  few  remarks  to  this  question. 

I  shall  offer  nothing  with  reference  to  the  nature  of  the  lesion  in  cirrhosis, 
as  conclusions  drawn  from  personal  researches.  This  branch  of  the  subject 
lies  within  the  domain  of  microscopy.  My  remarks  will  relate  to  the  views 
held  by  microscopical  observers.  There  is  considerable  unanimity  of  opinion, 
at  the  present  moment,  on  this  point.  The  primary  change  is  supposed  to 
consist  in  the  exudation  of  fibrin  into  the  interlobular  spaces,  and  the  pro- 
duction of  fibrous  tissue  in  this  situation.  The  microscope  reveals  an 
abnormal  abundance  of  this  tissue,  and,  indeed,  this  is  often  apparently 
obvious  to  the  naked  eye.  The  contraction  of  the  organ  is  attributed  to 
the  shrinking  of  this  newly  formed  tissue,  and  to  the  atrophy  of  the  lobules 
or  acini  caused  by  its  pressure  upon  them.  The  dropsy  is  explained  by  the 
pressure  of  the  exudation  and  newly  formed  tissue  on  the  terminal  branches 
of  the  vena  portae,  or  the  interlobular  veins,  which  occupy  the  same  situa- 
tion, viz.,  the  spaces  between  the  lobules.  Pressure  upon  these  venous 
radicles  produces  obstruction  within  the  liver  of  the  portal  circulation ; 
congestion  of  the  portal  vessels  of  the  abdominal  viscera  follows,  and 
serous  transudation  occurs  as  a  result  of  the  mechanical  pressure  on  the 
coats  of  the  vessels  incidental  to  the  portal  congestion.  The  nodulated 
appearance  and  deformation  of  the  liver  arise  from  the  exudation  and 
newly  formed  tissue  being  more  abundant,  or  the  shrinking  and  atrophy 
being  greater  in  some  parts  than  in  others.  The  anaemic  appearance  and 
dryness  in  many  cases,  together  with  the  wasting  of  the  liver  cells,  are 
other  consequences  of  pressure  within  the  liver.  The  point  of  departure 
being  the  exudation  of  fibrin,  and,  this  being  the  great  characteristic  of 
inflammation,  the  morbid  process  is  considered  to  be.  inflammatory.  Cir- 
rhosis, thus,  according  to  the  pathological  view  just  stated,  is  neither  more 
nor  less  than  a  diffused,  subacute  inflammation  of  the  connective  tissue, 
which  is  generally  supposed  to  exist  in  the  interlobular  spaces,  being  an 
extension  of  Glisson's  capsule.  This  is  an  epitome  of  the  pathology  of 
cirrhosis,  according  to  the  views  of  most  pathologists  at  the  present  time. 
The  rationale  just  given  is  not,  however,  accepted  by  all  pathologists.  Dr. 
Beale,  of  King's  College  Hospital,  London,  has  offered  a  different  doctrine.1 

1  Beale's  Archives  of  Medicine,  No.  2,  1858. 


310 


Flint,  Clinical  Keport  on  Hydro-Peritoneum. 


[April 


He  has  been  led  to  conclude  that  the  change  commences  in  the  cells  con- 
tained within  the  lobules  of  the  liver ;  the  cells  near  the  circumference  of 
the  lobules  being  first  affected,  and  the  affection  extending  gradually  from 
the  circumference  to  the  centre.  As  a  consequence  of  the  altered  condition 
of  the  liver  cells,  he  thinks  the  attractive  force  inherent  in  the  organ,  which 
determines  the  flow  of  portal  blood,  is  lessened ;  consequently  the  inter- 
lobular veins  shrink,  and  there  is  an  impediment  to  the  portal  circulation 
through  the  liver.  His  explanation  of  the  dropsy  is  the  same  as  that 
involved  in  the  commonly  received  doctrine  ;  it  is  the  result  of  pressure  on 
the  walls  of  the  portal  vessels  incidental  to  portal  congestion.  He  bases  his 
opinion  of  the  primary,  or  essential  change,  on  the  number  of  the  interlobu- 
lar vessels,  which  remain  permeable,  as  shown  by  injections ;  and  he  sup- 
poses that  the  appearance  of  an  abnormal  abundance  of  fibrous  tissue  may 
be  due  to  the  remains  of  the  wasted  and  shrunken  vessels  and  ducts,  rather 
than  to  the  presence  of  an  adventitious  tissue.  According  to  this  doc- 
trine, the  pathological  process  in  cirrhosis  is  not  inflammatory,  but  a 
degenerative  change,  having  its  point  of  departure  in  the  secreting  cells  of 
the  liver.  I  shall  not  enter  into  any  discussion  of  these  conflicting  views. 
The  question  is  to  be  settled,  not  by  discussion,  but  by  continued  microsco- 
pical researches. 

Contraction  of  the  liver,  apparently  from  external  compression,  may 
give  rise  to  hydro-peritoneum.  One  of  the  cases  afforded  an  example  of 
this  fact.  The  following  are  the  important  points  in  the  history  of  this 
case : — 

Caroline  E.,  aged  20,  of  small  size,  spine  curved,  sexual  system,  including 
mammae,  undeveloped,  was  attacked  with  hasmatemesis,  December,  1850. 
The  hemorrhage  was  copious,  but  ceased  after  six  hours.  She  was  at- 
tended by  the  late  Dr.  Wilcox  at  Buffalo.  Another  attack  of  haematemesis 
occurred  in  January,  1851.  In  February,  1851,  she  was  supposed  to  have 
peritonitis,  and  mercury  was  given  to  ptyalism.  About  this  date  the  accu- 
mulation of  liquid  in  the  peritoneal  sac  commenced.  In  March,  1851,  she 
had  another  attack  of  hasmatemesis.  The  peritoneal  dropsy  increased  in 
spite  of  the  use  of  digitalis  and  the  bitartrate  of  potassa;  and  she  was 
tapped  in  the  following  month  of  April.  She  was  tapped  again  in  May 
following.  Vomiting  then  became  a  prominent  symptom,  and  she  died  in 
June,  1851.  On  opening  the  abdomen,  and  giving  exit  to  a  large  quan- 
tity of  transparent  liquid,  the  parts  surrounding  the  liver  were  closely  and 
firmly  adherent  to  this  organ,  so  as  to  completely  conceal  it  from  view. 
The  adhesions  were  evidently  of  long  standing.  There  was  no  evidence  of 
recent  peritonitis.  The  liver,  when  the  adherent  parts  were  dissected  from 
it,  was  found  to  be  greatly  reduced  in  size,  irregularly  tabulated,  and  so 
deformed  that  the  organ  would  not  have  been  recognized.  The  weight  is 
not  noted.  The  internal  structure  was  not  examined.  The  ovaries  were 
small,  smooth,  and  transparent,  containing  no  corpora  lutea.  The  uterus 
was  extremely  small.    The  patient  had  never  menstruated. 

In  this  case  the  adhesions  of  the  liver  to  the  surrounding  parts  were 


1863.] 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


311 


manifestly  of  older  date  than  the  dropsy  ;  and  it  is  fair  to  conclude  that  the 
exudation  of  lymph  on  the  surface  of  the  organ  had  contributed  to  the 
atrophy  by  compression.  But  it  is  also  to  be  inferred  that  disease  of  the 
liver  existed  prior  to  the  serous  inflammation,  inasmuch  as  circumscribed 
peritonitis  does  not  occur,  except  as  secondary  to  an  affection  of  the  viscera 
with  which  the  affected  portion  of  peritoneum  is  connected. 

An  important  point  of  inquiry  relates  to  the  co-existence  of  affections 
of  other  organs  with  disease  of  the  liver.  What  other  affections  are  liable 
to  be  concerned,  proximately  or  remotely,  in  the  causation  of  hydro-peri- 
toneum ?  This  question  applies  particularly  to  affections  of  the  spleen, 
the  heart,  and  the  kidneys.  The  histories  of  the  fatal  cases  are  to  be 
interrogated  with  reference  to  these  organs. 

As  regards  the  spleen,  in  nine  of  the  histories  it  is  not  mentioned.  I 
am  certain  that  in  most,  if  not  all  these  cases,  this  organ  was  neither 
notably  increased  nor  diminished  in  volume.  In  one  case  it  is  noted  to 
have  been  small  and  wrinkled.  In  two  cases  the  volume  was  much  in- 
creased, being  larger,  and  also  greater  in  weight  than  the  liver.  In  two 
cases  the  weight  is  given,  being  in  one  2  lbs.  13  oz.  ;  and  in  the  other  18 
oz.  These  facts  show  that  notable  enlargement  of  the  spleen  is  the  excep- 
tion rather  than  the  rule,  and  that  the  organ  is  sometimes  diminished  in 
size.  There  is  no  ground,  so  far  as  these  facts  are  concerned,  to  suppose 
that  enlargement  of  the  spleen  plays  an  important  part  in  the  production 
of  peritoneal  dropsy.  And  when  it  is  considered  how  often  enlargement 
of  the  spleen  occurs  as  a  sequel  of  intermittent  fever  without  the  occur- 
rence of  dropsy,  we  must  regard  it  as  an  error  to  include  this  among  the 
causative  conditions  of  hydro-peritoneum.  It  is  so  included  by  most  au- 
thors of  works  on  the  practice  of  medicine.  The  infrequency  of  enlarge- 
ment of  the  spleen  in  fatal  cases  of  cirrhosis  would  not  be  anticipated,  and 
I  suspect  it  is  opposed  to  a  general  impression  among  practitioners.  It  is 
certainly  a  reasonable  &  priori  inference  that  a  degree  of  obstruction  to  the 
portal  circulation  within  the  liver,  giving  rise  to  congestion  of  the  ab- 
dominal viscera,  sufficiently  to  occasion  dropsical  effusion,  should  induce 
sufficient  congestion  of  the  spleen  to  increase  its  size.  The  fact,  however, 
that  the  spleen  is  enlarged  in  only  a  small  proportion  of  cases,  shows  other 
circumstances  than  portal  obstruction  to  be  requisite  in  the  production  of 
the  enlargement  when  it  does  occur. 

The  condition  of  the  heart  is  not  mentioned  in  the  notes  of  the  autopsies 
in  two  cases.  Of  the  remaining  ten  cases,  in  two  there  existed  universal, 
old  pericardial  adhesions.  In  one  of  these  two  cases  the  heart  was  en- 
larged, weighing  14  oz. ;  in  the  other  case  the  organ  was  below  the  normal 
size.  There  was  rigidity  of  the  aortic  valves  and  enlargement  (weight  11 
oz.)  in  one  case.  The  heart  is  noted  as  healthy  in  all  the  remaining,  viz., 
in  seven  cases.  These  results  do  not  go  to  sustain  a  common  impression 
that  disease  of  the  heart  precedes  and  has  a  causative  relation  to  cirrhosis 


312 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


[April 


of  the  liver.  When  these  two  organs  are  affected  together,  the  association 
is  probably  a  coincidence  only.  The  physical  signs  enabling  us  now  to 
determine  positively  the  existence  or  absence  of  cardiac  lesions,  the  question 
as  to  the  condition  of  the  heart  in  cases  of  hydro-peritoneum,  will  come  up 
again  when  the  histories  of  the  non-fatal  cases  are  considered. 

The  condition  of  the  kidneys  is  noted  in  all  but  three,  that  is,  in  11 
cases.  These  organs  were  considered  to  be  healthy  in  5  of  these  ten  cases/ 
In  the  remaining  6  cases  they  were  manifestly  diseased.  In  one  case  it  is 
simply  stated  that  they  presented  the  appearance  of  "  incipient  granular 
degeneration."  In  all  the  other  cases  they  were  enlarged  and  granular. 
In  2  cases  fatty  degeneration  was  marked.  Coexisting  disease  of  the 
kidneys,  thus,  it  would  seem,  occurs  in  a  sufficiently  large  proportion  of 
cases  to  show  either  some  pathological  connection  between  the  affection  of 
these  organs  and  of  the  liver,  or  that  both  affections  are  effects  of  the  same 
causative  conditions.  The  existence  of  a  relation  of  causation  between  the 
two  affections,  and,  if  such  a  relation  exists,  the  question  whether  the 
affection  of  the  kidneys  proceeds  from  disease  of  the  liver,  or  vice  versa, 
are  to  be  determined  by  ascertaining  in  a  sufficiently  large  collection  of 
cases  which  of  the  affections  occurs  prior  to  the  other.  The  facts  noted 
with  respect  to  the  autopsies  in  the  fatal  cases  now  under  consideration, 
are  insufficient  to  shed  light  on  these  points.  The  same  questions,  how- 
ever, will  occur  in  connection  with  the  histories  of  the  non-fatal  cases, 
inasmuch  as  the  presence  of  albumen  in  the  urine  may  be  considered  as  a 
pretty  uniform  criterion  of  the  existence  of  disease  of  the  kidneys.  It  is 
worthy  of  remark  that  in  none  of  the  cases  in  which  disease  of  the  kidneys 
coexisted,  were  these  organs  contracted,  a  fact  which  renders  the  absence 
of  albumen  in  the  urine  more  reliable  as  evidence,  in  cases  of  hydro-peri- 
toneum, that  the  kidneys  are  not  diseased,  since  it  is  chiefly  in  cases  of 
contracted  kidneys  that  we  meet  with  the  exceptional  instances  in  which 
albuminuria  is  wanting. 

As  regards  other  organs  than  the  spleen,  heart,  and  kidneys,  there 
existed  double  pleurisy  in  one  case,  with  considerable  effusion  of  lymph 
and  serum  in  both  sides.  In  this  case  there  were  old  pericardial  adhesions, 
and  the  kidneys  were  diseased.  In  another  case  there  existed  oedema  of 
the  lungs.  In  this  case,  also,  old  pericardial  adhesions  existed.  In  one 
case  there  were  ulcerations  in  the  large  intestine.  In  one  case  there  was  a 
deposit  of  lymph  beneath  the  arachnoid  on  the  superior  portion  of  the 
cerebral  hemispheres.  The  lungs  were  stated  to  be  healthy  in  5  of  the 
cases. 

Reviewing  the  foregoing  results,  the  only  constant  lesions  were  in  the 
liver.  Undoubtedly  this  organ  is  affected  in  the  vast  majority  of  fatal 
cases  of  hydro-peritoneum  ;  and  undoubtedly,  in  the  vast  majority  of  cases, 
the  affection  of  the  liver  is  of  that  kind  known  as  cirrhosis.  Enlargement 
of  the  liver  from  fatty  or  other  deposit,  was  found  in  only  one  of  the  cases. 


1863.]         Flint,  Clinical  Eeport  on  Hydro-Peritoneum.  313 

The  purely  fatty  liver  certainly  does  not  give  rise  to  peritoneal  effusion. 
Having  met  with  a  large  number  of  examples  of  the  latter  in  hospital 
practice,  I  am  warranted  in  speaking  thus  positively  on  this  point.  But 
that  an  abnormal  amount  of  fatty  deposit  may  coexist  with  the  changes 
giving  rise  to  peritoneal  dropsy  is  undoubtedly  true,  although  it  is  an 
exception  to  the  rule.  This  was  the  fact  in  two  of  the  cases  analyzed  ;  and 
in  one  of  these  cases  the  amount  of  fatty  deposit  coexisting  with  cirrhosis 
was  sufficient  to  cause  considerable  enlargement  of  volume,  the  weight 
being  6  lbs.  6  oz.  Whatever  views  may  be  held  respecting  the  point  of 
departure,  or  the  nature  of  the  changes  in  cirrhosis,  it  seems  to  be  clear 
that  the  dropsy  in  fatal  cases  is  due  to  congestion  of  the  portal  system 
arising  from  obstruction  to  the  free  passage  of  the  portal  blood  through 
the  liver.  Fatty  deposit  does  not  involve  this  obstruction  sufficiently  to 
produce  dropsy ;  and  this  remark  holds  good  with  respect  to  carcinoma  of 
the  liver,  and  of  the  deposit  known  as  lardaceous,  certainly  in  the  majority 
of  cases.  It  is  easy,  however,  to  understand  that  portal  obstruction  and 
consequent  congestion,  sufficient  to  produce  dropsy,  may  occur  independ- 
ently of  any  hepatic  lesion.  Obstruction  of  the  vena  portse  may  arise  from 
a  coagulum  within  the  vein,  or,  by  outward  pressure  from  a  tumour  press- 
ing upon  the  vein,  examples  of  which  have  been  reported.  That  enlarge- 
ment of  the  spleen  may  give  rise  to  hydro-peritoneum  is  not  probable.  In 
cases  of  dropsy  attributed  to  this  organ,  it  is  fair  to  presume  that  coexist- 
ing disease  of  the  liver  or  some  other  causative  condition  was  overlooked. 
Disease  of  the  heart  is  not  associated  sufficiently  often  with  cirrhosis  to 
assume  that  any  pathological  connection  exists  between  the  two  affections 
when  they  are  found  together :  the  union  is  to  be  regarded  only  as  a  coin- 
cidence. Disease  of  the  kidney,  on  the  other  hand,  is  associated  in  fatal 
cases  sufficiently  to  suggest  the  probability  of  some  pathological  connection, 
but  whether  one  conduces  to  the  other,  and,  if  so,  which  stands  to  the 
other  in  the  relation  of  causation,  or  whether  both  are  in  the  relation  of 
effects  of  a  common  cause,  remain  to  be  ascertained.  Other  affections 
found  in  fatal  cases,  such  as  meningitis,  pleurisy,  pulmonary  oedema,  doubt- 
less occur  as  coincidences. 

It  is  to  be  borne  in  mind  that  thus  far  the  causation  of  hydro-peritoneum 
has  been  considered  with  reference  to  the  facts  obtained  after  death.  Of 
course,  attention  has  been  limited  to  fatal  cases.  The  source  of  the  affection 
in  the  few  cases  which  end  in  recovery,  will  be  one  of  the  points  of  inquiry 
in  proceeding  now  to  consider  those  facts  pertaining  to  the  histories  during 
life  which  had  a  bearing  on  the  causation.  These  facts  are  to  be  considered 
with  reference  to  their  causative  influence  either  proximately  or  remotely, 
in  other  words,  as  concerned  immediately  in  the  production  of  the  dropsy, 
or  as  conducive  to  abnormal  conditions  on  which  the  dropsy  is  immediately 
dependent.    Directing  attention,  first,  to  the  most  frequent  and  efficient 


314.  Flint,  Clinical  Report  on  Hydro-Peritoneum.  [April 

of  the  remote  causes,  I  will  interrogate  the  histories  respecting  the  habits 
of  the  patients  as  regards  the  use  of  alcoholic  stimulants. 

Of  20  fatal  cases,  in  the  histories  of  which  the  habits  of  the  patients 
as  respects  drinking  are  stated,  in  17  intemperance  was  acknowledged.  In 
only  three  of  these  cases  was  intemperance  denied  ;  and  in  one  of  these  3 
cases  the  patient  admitted  the  habit  of  drinking,  but  not  to  excess.  Of  20 
non -fatal  cases,  in  12  intemperance  was  acknowledged.  In  6  cases  intem- 
perance was  denied,  but  in  3  of  these  6  cases  moderate  drinking  was 
admitted.  In  2  cases  only  was  it  certain  that  the  patients  were  not  in  the 
habit  of  drinking,  in  one  case  the  patient  being  a  child  twelve  years  old. 
Thus,  of  40  cases,  fatal  or  non-fatal,  intemperance  was  acknowledged  in 
29 ;  in  4,  moderate  drinking  was  acknowledged,  leaving  T  cases  in  which 
the  use  of  alcoholic  stimulants  was  not  ascertained ;  and  of  these  7  cases 
in  2  only  was  it  certain  that  alcoholic  stimulants  were  not  used  to  excess. 
Of  the  29  cases  in  which  intemperance  was  acknowledged,  in  24  the  form 
of  alcoholic  stimulant  used  was  noted,  that  is,  whether  spirits,  wine,  or 
malt  liquors.  In  all  these  cases,  with  a  single  exception,  spirits  were 
used.    In  the  excepted  case  the  patient  stated  that  he  drank  only  beer. 

As  regards  the  mode  of  drinking,  of  the  23  cases  in  which  spirits  were 
used,  in  15  information  is  noted  in  the  histories.  And  in  all  of  these  15 
cases,  the  mode  of  drinking  was,  to  take  raw  spirits  at  different  periods  of 
the  day,  before  breakfast,  and  at  other  times,  on  the  empty  stomach,  a 
little  water  being  drank  generally  after  the  spirits.  In  the  remaining  8 
cases,  the  histories  contain  no  information  on  this  point.  This  result  is 
striking,  and  accords  with  the  view  which  other  clinical  observers  have 
entertained,  viz.,  that  the  habit  of  drinking  spirits  undiluted  on  an  empty 
stomach,  leads  to  the  production  of  cirrhosis  of  the  liver.  So  far  as  the 
facts  are  recorded  with  reference  to  this  point  in  this  collection  of  cases, 
this  was  the  rule,  without  a  single  exception,  among  the  patients  addicted 
to  spirit-drinking. 

As  regards  the  length  of  time  during  which  the  habit  of  spirit-drinking 
had  existed,  facts  are  noted  in  18  cases.  In  all,  the  habit  had  existed  for 
a  long  time.  In  one  case  the  duration  was  25  years  ;  two  patients  stated 
that  they  had  drank  daily  from  boyhood ;  in  4  cases  the  duration  was  10 
years ;  in  one  case  8  years,  and  in  the  remaining  cases  it  is  simply  noted 
that  the  habit  had  existed  for  several  years,  or  for  a  long  period.  In  5 
cases  it  is  noted  that,  for  some  time  prior  to  the  development  of  hydro- 
peritoneum  (in  the  one  case  two,  and  in  the  other  case  three  months),  the 
patients  had  drank  comparatively  little,  having  been  so  situated  as  not  to 
be  able  to  obtain  liquor.  This  is  interesting  as  going  to  show  that  other 
causes  than  the  continued  use  of  spirits  may  determine  the  epoch  of  the 
occurrence  of  dropsy.  The  kind  of  spirit  drank  is  noted  in  11  cases;  and  in 
9  of  these  it  was  whiskey,  in  one  case  it  was  brandy,  and  in  one  gin  and 


1863.] 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


315 


brandy  were  drank.  The  preponderance  of  cases  in  which  whiskey  was 
used  may  be  readily  explained  by  the  fact  that  this  is  the  liquor  commonly 
drank  by  persons  in  the  station  to  which  most  of  the  patients  belonged. 

The  foregoing  results  prove  the  agency  of  the  prolonged  use  of  spirits 
in  the  causation  of  hydro-peritoneum.  They  warrant  the  conclusion  that 
when  the  dropsy  depends  on  cirrhosis  of  the  liver,  the  abuse  of  alcoholic 
stimulants  is  to  be  inferred.  In  all  the  fatal  cases  in  which  an  autopsy  was 
made,  and  the  existence  of  cirrhosis  thus  positively  ascertained,  intemper- 
ance was  known  to  have  existed,  save  in  the  case  of  greatly  contracted 
liver  with  old  and  firm  peritoneal  adhesions;  in  this  excepted  case  the 
habits  of  the  patient  were  not  noted,  but  it  may  be  presumed  they  were 
good.  The  diagnosis  of  hydro-peritoneum  dependent  on  cirrhosis,  thus, 
renders  it  altogether  probable  that  patients  have  been  addicted  to  the  use 
of  alcoholic  stimulants ;  and,  in  hospital  practice,  it  is  generally  safer  to 
rely  upon  this  law  of  etiology  than  to  trust  to  the  statements  of  patients 
when  the  habit  of  drinking  is  denied.  This  remark  is  especially  applicable 
to  females,  whose  statements  with  regard  to  habits,  as  experience  has 
taught  me,  are  much  less  reliable  than  those  of  male  patients  ;  the  explana- 
tion, probably,  being  that  the  sense  of  shame  in  acknowledging  vicious 
habits  is  greater  in  females  <(than  in  males.  The  frequent  occurrence  of 
cirrhosis  in  drunkards  is  not  new,  but  according  to  some  writers  this 
affection  occurs  not  infrequently  in  those  who  are  not  intemperate.  For 
example,  Dr.  Wood,  in  his  work  on  Practice,  says  that  a  large  proportion 
of  the  patients  who  have  come  under  his  notice  have  been  of  temperate 
habits.  This  assertion  is  at  variance  with  the  facts  which  have  been  pre- 
sented, and  I  can  only  account  for  it  by  supposing  that  Dr.  Wood  has 
been  deceived  by  patients  with  respect  to  their  habits. 

The  inquiry  arises  here,  How  does  alcohol  act  on  the  liver  to  produce 
cirrhosis  ?  The  explanation  now  commonly  received  is,  that  the  alcohol 
passing  readily  into  the  portal  blood,  and  carried  at  once  to  the  liver,  gives 
rise  to  inflammation  of  a  low  grade  in  the  interlobular  spaces,  and  that 
exudation  occurs  in  this  situation  as  a  result  of  inflammatory  action. 
This  explanation  is  supposed  to  be  sustained  by  the  mode  of  drinking 
shown  to  conduce  especially  to  cirrhosis,  viz.,  taking  raw  spirits  on  an 
empty  stomach.  The  explanation  is  plausible,  but  it  must  be  considered  as 
hypothetical.  The  facts  are  perhaps  not  less  consistent  with  the  hypo- 
thesis of  cirrhosis  being  a  degeneration  taking  its  point  of  departure  from 
the  cells  of  the  lobules. 

What  causes  may  co-operate  with  the  abuse  of  alcohol  in  giving  rise  to 
hydro-peritoneum,  and  how  is  the  affection  to  be  accounted  for  in  excep- 
tional cases  which  end  in  recovery  ?  There  are  reasons,  derived  from  the 
clinical  history  of  the  affection,  for  believing  that  when  the  dropsy  is 
dependent  on  cirrhosis,  and  the  cirrhosis  on  the  habit  of  spirit-drinking, 
auxiliary  causes  are  often  involved.    Were  it  not  so,  the  prognosis  in  cases 


316  Flint,  Clinical  Report  on  Hydro-Peritoneum.  [April 

of  dropsy  in  the  intemperate  would  be  even  more  unfavourable  than  it  is. 
I  may  mention  as  a  reason  for  believing  that  auxiliary  causes  are  often 
involved,  that,  when  the  dropsical  effusion  begins,  it  is  apt  to  increase 
rapidly,  leading  in  a  short  time  to  distension  of  the  abdomen.  This  would 
not  be  expected  were  the  dropsy  dependent  exclusively  on  the  cirrhosis 
which  has  been  slowly  going  on  for  months  or  even  years.  It  is  not  pro- 
bable that  the  hepatic  lesions  undergo  any  marked  increase  at  the  time 
when  dropsy  occurs ;  what  then  determines  the  time  of  its  occurrence,  and 
why  should  it  be  developed  to  so  great  a  degree  in  so  short  a  period  as  is 
frequently  observed  ?  Another  reason  which  may  be  mentioned  is,  the 
frequent  occurrence  of  cedema  of  the  lower  extremities  prior  to  the  develop- 
ment of  dropsy  of  the  peritoneum.  It  will  be  seen  when  we  come  to  con- 
sider the  clinical  history  of  the  affection,  that  such  is  the  fact.  And  this 
fact  points  to  the  existence  of  other  causes  of  dropsy  than  the  hepatic 
lesions.  Finally,  the  occurrence  of  cases  of  hydro-peritoneum  ending  in 
recovery,  cases  which,  although  rare,  do  occur,  is  proof  that  the  affection 
may  arise  independently  of  cirrhosis  or  any  other  irremediable  structural 
lesions.  I  shall  proceed  to  interrogate  the  histories  with  reference  to  any 
circumstances  showing  causative  influences  aside  from  the  effects  of  alcoholic 
stimulants.  I  shall  reserve  the  pre-existence  of  cardiac  and  renal  disease 
for  subsequent  inquiry. 

In  22  cases  the  histories  show  affections  immediately  antecedent  to  the 
dropsy,  which  may  fairly  be  supposed  to  have  operated  as  auxiliary  causes. 
The  facts  in  these  cases  are  as  follows  :  In  10  cases  the  dropsy  followed 
intermittent  fever,  the  patients  having  been  subject  to  relapses  of  this  dis- 
ease for  a  greater  or  less  period.  In  several  of  these  cases  the  relapse 
immediately  preceding  had  not  been  arrested,  and  the  patients  had  suffered 
from  the  disease  for  several  weeks.  In  2  of  these  cases  the  dropsy  was 
developed  after  the  patients  had  been  admitted  into  hospital.  In  one 
case  the  patient  had,  in  addition,  chronic  ulcers  of  the  leg  dependent  on 
syphilis,  and  in  one  case  an  attack  of  epidemic  cholera  had  preceded  the 
intermittent  fever.  In  3  cases  the  dropsy  was  preceded  by  haematemesis, 
the  quantity  of  blood  vomited  being  considerable.  In  2  cases  the  patients 
were  females,  and  had  been  confined  shortly  before  the  development  of  the 
dropsy.  One  of  these  cases  ended  in  recovery,  and  in  this  case  it  was  cer- 
tain that  the  patient  was  not  addicted  to  the  use  of  alcoholic  stimulants. 
Diarrhoea  preceded  the  dropsy  for  several  weeks  in  2  cases.  In  one  case 
the  patient  was  admitted  for  dysentery,  and  the  dropsy  was  developed  after 
his  admission.  In  one  case  the  patient  was  admitted  with  pneumonia,  and 
the  dropsy  was  developed  during  convalescence  from  that  disease.  The 
patient  also  had  chronic  ulcers  of  the  leg.  In  one  case  the  dropsy  was 
developed  during  convalescence  from  rheumatism  ;  and  in  one  case  during 
convalescence  from  a  fever  of  a  month's  duration,  supposed  to  be  typhoid 
fever.    In  one  case  the  patient  was  admitted  for  a  syphilitic  eruption,  and 


1863.]         Flint,  Clinical  Report  on  Hydro-Peritoneum.  311 

was  nearly  ready  to  be  discharged  from  the  hospital  when  the  dropsy  made 
its  appearance. 

I  think  it  is  very  probable  that  among  the  other  cases  than  the  22  just 
referred  to,  antecedent  affections,  or  circumstances  may  have  existed  in 
some,  to  which  the  dropsy  was  measurably  attributable,  for  many  of  these 
the  histories  are  defective  as  regards  the  events  or  condition  of  the  patients 
prior  to  the  development  of  the  dropsy.  But,  making  no  account  of  this 
supposition,  in  nearly  one-half  of  this  collection  of  cases  it  may  be  assumed 
that  the  dropsy  was  proved  by  morbid  conditions  associated  either  with 
cirrhosis  of  the  liver,  or  with  whatever  may  have  been  the  affection  on 
which  the  dropsy  was  immediately  dependent. 

The  antecedent  affections  were  remotely  concerned  in  the  causation  of 
the  dropsy,  acting,  as  may  be  supposed,  by  deteriorating  the  blood,  weaken- 
ing the  circulation,  or  lowering  the  vigour  of  the  body.  Had  these  associated 
morbid  conditions  not  existed,  the  occurrence  of  the  dropsy  might  have 
been,  to  say  the  least,  postponed.  This  is  an  important  consideration  in 
connection  with  the  treatment,  and  the  course  of  the  disease  in  certain 
cases  will  be  found  to  sustain  the  view  just  presented.  It  is  worthy  of 
note  that  in  5  cases  patients  were  received  into  hospital  for  antecedent 
affections,  the  dropsy  being  developed  after  admission.  It  is  to  be  added 
that  the  22  cases  are  divided  equally  among  those  which  were  fatal  and 
those  which  were  non-fatal,  i.  e.,  eleven  in  each  division. 

In  the  foregoing  interrogation  with  respect  to  affections,  etc.,  antecedent 
to  the  dropsy,  I  did  not  embrace  cardiac  and  renal  disease.  In  the  cases  in 
which  disease  of  the  heart  or  kidneys  coexisted  with  the  dropsy,  it  is  fair 
to  infer  that  the  former  preceded  the  latter ;  and  it  is  also  to  be  inferred 
that,  in  some  of  the  cases,  at  least,  the  disease  of  the  heart  and  kidneys 
contributed  to  the  development  of  the  dropsy.  Directing  attention,  first, 
to  the  coexistence  of  disease  of  the  heart,  it  has  been  seen  that,  of  ten  of 
the  fatal  cases  in  which  post-mortem  examinations  were  made  (the  condi- 
tion of  the  heart  being  noted  in  only  these  ten  cases),  this  organ  was  the 
seat  of  disease  in  but  three  cases.  In  one  of  these  three  cases  pericardial 
adhesions,  existing  without  enlargement,  were  probably  innocuous ;  in  the 
other  two  cases,  the  heart  being  enlarged,  some  influence  in  the  production 
of  the  dropsy  may  be  suspected.  Of  the  cases,  fatal  and  non-fatal,  exclu- 
sive of  those  in  which  autopsies  were  made,  the  existence,  or  otherwise,  of 
cardiac  disease  as  determined  by  means  of  physical  exploration,  was  noted 
in  twenty-two.  Of  these  22  cases  in  15  there  were  no  physical  signs  of 
disease  of  the  heart.  Of  the  remaining  7  cases,  in  4  a  systolic  murmur 
existed  at  the  base,  and  the  organ  was  not  enlarged.  Eliminating  these  4 
cases  as  cases  in  which  the  existence  of  organic  lesions  was  doubtful,  and  in 
which  the  lesions  were  innocuous,  if  they  existed,  since  there  was  no  enlarge- 
ment, there  remain  3  cases.  In  these  3  cases  there  were  mitral  lesions  and 
enlargement  of  the  heart,  and,  hence,  some  influence  in  the  production  of  the 


318 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


[April 


dropsy  may  be  suspected.1  Thus,  of  32  cases  in  which  the  condition  of 
the  heart  was  nested,  as  determined  either  by  autopsical  examination  or  by 
physical  signs,  in  5  cases  only  were  there  lesions  involving  enlargement  of 
this  organ.  Here  we  have  again  exemplified  the  fact  that  disease  of  the 
heart  is  not  associated  sufficiently  often  with  the  morbid  condition  on  which 
hydro-peritoneum  is  immediately  dependent  (in  cirrhosis  of  the  liver  in  the 
vast  proportion  of  cases),  to  show  the  existence  of  any  pathological  con- 
nection between  the  two.  When  the  two  are  associated,  however,  it  is  not 
improbable  that  the  disease  of  the  heart  may  act  as  an  auxiliary  cause  in 
the  development  of  the  peritoneal  dropsy.3 

As  regards  coexisting  disease  of  the  kidneys,  it  will  be  recollected  that  of 
11  autopsies  in  which  the  condition  of  these  organs  is  noted,  they  were 
considered  to  be  diseased  in  six.  Hence  it  was  surmised  that  there  might 
have  been  in  these  cases  some  pathological  connection  between  disease  of 
the  kidneys  and  cirrhosis  of  the  liver,  consisting  either  in  a  dependence  of 
one  upon  the  other  to  a  greater  or  less  extent,  or  in  both  being  effects 
of  the  same  causes.  It  was  stated  that  the  question  of  a  pathological 
connection  would  again  come  up  in  connection  with  the  cases  in  which 
autopsies  are  not  embraced  in  the  histories,  inasmuch  as  the  presence  of 
albumen  in  the  urine  may  be  considered  as  evidence  of  disease  of  the  kid- 
neys, and  vice  versa.  An  interrogation  of  the  cases  with  reference  to  albu- 
minuria leads  to  the  following  results:  in  18  cases  (six  fatal  cases  in  which 
autopsies  were  not  made  and  twelve  non-fatal  cases),  the  histories  contain 
information  on  this  point,  and  in  not  one  of  these  cases  was  the  urine 
found  to  be  albuminous.  In  most  of  the  other  cases  the  urine  was  un- 
doubtedly tested  for  albumen,  and,  had  it  existed,  the  fact  would  have  been 
noted,  so  that  the  absence  of  albuminuria  may  be  inferred  in  these  cases. 
Of  the  11  fatal  cases  in  which  autopsies  were  made,  the  kidneys,  as  just 
stated,  were  considered  as  diseased  in  6.  Of  these  6  cases,  the  histories 
state  that  albumen  was  not  found  in  3 ;  in  1  case  the  urine  was  slightly 
albuminous,  and  in  1  case  the  condition  of  the  urine  was  not  noted.  Of 
the  5  cases  in  which  autopsical  examination  revealed  no  disease  of  the 
kidneys,  in  all  albumen  was  not  present  in  the  urine. 

These  facts  are  interesting  in  connection  with  the  results  of  the  examina- 
tions after  death  as  regards  disease  of  the  kidneys.    Taking  albuminuria  as 

1  In  two  of  these  3  cases  the  ages  were  respectively  12  and  13  years. 

2  It  is  perhaps  generally  supposed  that  cirrhosis  and  disease  of  the  heart  are 
frequently  associated.  M.  Becquerel,  in  his  essay  on  cirrhosis  (Archives  G4n6rales% 
1840),  stated  that  of  42  cases  disease  of  the  heart  coexisted  in  21.  But  of  these  21 
cases  in  13  the  cirrhosis  was  considered  to  he  in  the  first  degree,  giving  rise  to 
trifling  symptoms  or  none  whatever.  Dr.  Budd  (on  diseases  of  the  liver),  says 
"  it  is  perhaps  fair  to  infer  that,  in  some  of  these  cases,  M.  Becquerel  mistook  for 
the  first  stage  of  cirrhosis  the  nutmeg  appearance  of  the  liver  produced  by  partial 
congestion  of  the  capillaries." 


1863.]         Flint,  Clinical  Report  on  Hydro-Peritoneum.  319 

a  diagnostic  criterion  of  disease  of  the  kidneys,  the  latter  very  rarely  co- 
exists with  hydro-peritoneum,  or  with  the  affection  existing  in  the  great 
majority  of  cases,  viz.  cirrhosis  of  the  liver.  The  results  of  autopsical  exa- 
minations and  of  examinations  of  the  urine  for  albumen  are  not  in  accord- 
ance, the  former  going  to  show  a  large,  and  the  latter  a  very  small  pro- 
portion of  cases  in  which  disease  of  the  kidneys  coexists.  And  of  the  6 
cases  in  which  the  kidneys  were  found  to  be  diseased  after  death,  in  3  the 
urine  is  noted  to  be  not  albuminous.  It  would  seem,  from  these  facts,  as 
if  disease  of  the  kidneys  is  apt  to  coexist  with  hydro-peritoneum  without 
being  manifested  by  albumen  in  the  urine. 

On  what  pathological  conditions  is  hydro-peritoneum  dependent  when  it 
ends  in  recovery  ?  Cirrhosis  of  the  liver  being  an  incurable  lesion,  when 
the  dropsy  is  dependent  thereon,  recovery  is  hardly  to  be  expected.  It  will 
be  seen  hereafter  that,  although  this  lesion  in  all  probability  exists,  an 
apparent  recovery  sometimes  takes  place ;  that  is,  the  dropsical  effusion 
may  be  removed,  and  a  reaccumulation  not  occur  for  a  greater  or  less  pe- 
riod. But  the  dropsy  sometimes  occurs  under  circumstances  which  render 
it  probable  that  cirrhosis  does  not  exist,  and  the  recovery  may  be  complete 
and  permanent.  I  have  met  with  "a  striking  instance  of  this  kind.  The 
following  are  the  important  facts  contained  in  the  history: — 

Mrs.  W.,  aged  about  24,  had  had  two  children,  the  youngest  being  5  or 
6  months  old,  which  she  was  nursing.  The  patient  came  under  my  obser- 
vation in  March,  1861.  She  was  under  the  care  of  Dr.  Dudley,  of  Brook- 
lyn. Enlargement  of  the  abdomen  had  been  first  observed  shortly  before 
I  saw  her.  The  enlargement  was  evidently  due  to  liquid  in  the  peritoneal 
sac.  The  amount  of  liquid  was  sufficient  to  cause  considerable  enlarge- 
ment, but  not  to  render  the  abdominal  walls  tense.  She  complained  of 
slight  pain  over  the  false  ribs  on  both  sides.  The  abdomen  was  not  tender 
on  pressure.  The  spleen  appeared  to  be  moderately  enlarged;  the  liver 
seemed  to  be  neither  enlarged  nor  contracted.  She  had  febrile  paroxysms 
occurring  irregularly,  ushered  in  by  chilly  sensations  and  followed  by  sweat- 
ing. Thes"e  speedily  ceased  under  the  use  of  quinia  in  full  doses.  There 
was  no  oedema  of  face  or  limbs.  The  urine  was  not  albuminous.  She  was 
moderately  anaemic.  There  were  no  symptoms  or  signs  of  pulmonary  or 
cardiac  disease. 

When  the  febrile  paroxysms  just  mentioned  were  arrested,  the  dropsy 
diminished,  but,  in  a  short  time,  the  accumulation  of  liquid  was  greater 
than  before.  Elaterium,  given  to  produce  free  hydragogue  operations, 
caused  the  dropsy  temporarily  to  disappear,  but  the  patient  was  greatly 
weakened  by  this  remedy.  She  was  treated  with  the  iodide  of  potassium, 
and  the  citrate  of  iron  and  quinia,  with  generous  diet.  Under  this  treat- 
ment the  affection  remained  stationary  up  to  the  latter  part  of  June.  She 
was  then  advised  to  begin  to  go  out  of  doors,  which,  owing  to  general 
weakness,  she  did  at  first  with  considerable*  difficulty.    From  this  time  she 


320  Flint,  Clinical  Report  on  Hydro-Peritoneum.  [April 

began  to  improve.  Shortly  afterward  she  went  into  the  country  and  all 
remedies  were  discontinued.  She  continued  to  improve;  and  during  the 
summer  the  dropsy  entirely  disappeared  and  she  regained  perfect  health, 
which  she  has  preserved  up  to  this  time.  The  patient  was  also  seen  in 
consultation  by  Prof.  Willard  Parker. 

This  case  shows  that  hydro-peritoneum  may  occur,  persist  for  several 
months,  then  disappear,  and  complete  recovery  ensue.  The  position  and 
character  of  this  patient  rendered  it  certain  that  the  usual  source  of  cir- 
rhosis, viz.,  use  of  alcoholic  stimulants,  was  not  involved  in  the  causation. 
The  supposition  of  subacute  peritonitis  is  hardly  admissible,  in  view  of  the 
absence  of  the  local  symptoms  of  inflammation  and  of  pulmonary  tuber- 
culosis, together  with  the  abundance  of  the  liquid  effusion.  I  confess  an 
inability  to  offer  any  explanation  in  this  or  other  similar  instances  ;  I  cite 
the  case  chiefly  in  illustration  of  the  fact  that  the  affection  may  depend  on 
causative  conditions  which  are  temporary  and  lead  to  no  serious  results. 
This  fact  is  important  to  be  considered  in  connection  with  the  prognosis 
in  certain  cases ;  but,  unhappily,  examples  like  the  one  just  cited  are  ex- 
ceedingly rare.  Doubtless  the  anaemia  and  general  debility  incident  to  lac- 
tation contributed  to  the  development  'of  the  dropsy  in  the  case  just  cited, 
but  there  must  have  existed,  in  addition,  some  pathological  condition 
determining  the  seat  of  the  affection. 

It  remains  to  consider  the  influence  of  age,  sex,  and  civil  condition  on 
the  causation.  The  age  is  stated  in  43  of  the  cases.  The  greatest  age  is 
6D  years,  one  patient  only  being  as  old  as  this.  The  next  highest  is  60, 
the  next  53,  two  patients  being  as  old  as  the  latter  age.  With  the  excep- 
tion of  one  patient,  who  was  51,  all  the  remainder  were  50  or  under.  In 
8  cases  the  ages  were  between  40  and  50  ;  in  13  cases  between  30  and  40  ; 
in  10  between  20  and  30  ;  in  one  case  the  age  was  12,  and  in  another  case 
the  age  was  13  years.  In  the  two  cases  last  enumerated,  there  existed 
mitral  lesions  with  enlargement  of  the  heart.  Hydro-peritoneum,  thus, 
occurs  in  the  great  majority  of  cases  over  20  and  under  50  years  of  age, 
the  larger  proportion  of  cases  being  between  30  and  40  years.  These 
results  are  consistent  with  the  fact  that  in  most  cases  the  affection  is  due 
to  the  more  or  less  prolonged  use  of  alcoholic  stimulants.  Habits  of  intem- 
perance, if  formed  prior  to  20  years  of  age,  have  not  been  sufficiently 
prolonged  to  produce  cirrhosis,  and  it  is  rare  for  persons  to  become  intem- 
perate after  the  age  of  50. 

As  regards  sex,  of  45  cases,  36  were  males  and  9  females.  The  large 
preponderance  of  the  former  is  doubtless  owing  to  the  proportionately 
greater  prevalence  of  intemperance  among  males  than  among  females. 

In  the  occupations  of  the  patients  nothing  appears  to  show  any  special 
influence  derived  from  this  source.  Sixteen  were  labourers,  three  were  car- 
penters, two  were  brewers,  and,  among  the  remainder,  the  following  occu- 
pations had  each  a  single  representative:  storekeeper,  carver,  butcher,  clerk, 


1863.]         Flint,- Clinical  Report  ou  Hydro-Peritoneum.  321 

tailor,  and  tinsmith.  In  the  great  majority  of  the  cases  having  been  ob- 
served in  hospital  practice,  very  few  were  from  the  higher  walks. in  life. 
But  that  the  great  majority  of  cases  were  observed  in  hospitals,  is  owing 
to  the  comparative  infrequency  of  the  affection  among  the  better  class  of 
patients  in  private  practice.  This  is,  doubtless,  owing  to  the  dependence 
of  cirrhosis  on  spirit-drinking,  and  in  a  measure,  at  least,  on  a  mode  of 
spirit-drinking  which  is  much  more  in  vogue  among  the  labouring  than 
among  the  intemperate  portion  of  the  so-called  better  classes  of  society. 
The  questions  might  be  raised  whether  spirituous  liquors  of  a  bad  quality 
may  not  especially  lead  to  cirrhosis,  and  whether  the  use  of  such  liquors 
may  not  be  a  reason  for  the  prevalence  of  the  affection  among  the  labouring 
classes.  In  other  words,  is  cirrhosis  purely  an  effect  of  alcohol,  or  does  it 
proceed,  to  a  greater  or  less  extent,  from  other  principles  contained  in 
spirituous  liquors  ?  I  must  content  myself  with  raising  these  questions. 
I  am  not  prepared  to  answer  them.  I  have  heard  it  said  by  medical  men 
in  Kentucky  that  the  pure  form  of  whiskey  made  in  that  State  never  causes 
cirrhosis,  but  I  cannot  vouch  for  the  correctness  of  this  statement. 

Leaving,  now,  the  consideration  of  the  causation  of  hydro-peritoneum, 
the  conclusions  drawn  from  the  results  of  the  analysis  of  the  cases  in  this 
collection  may  be  summed  up  as  follows  : — 

The  immediate  causative  condition  in  fatal  cases  pertains  to  the  liver. 
Jhis  organ,  as  a  rule,  is  contracted  and  diminished  in  weight ;  the  surface 
may  be  either  smooth  or  nodulated  (hob-nailed),  and  it  is  sometimes  nota- 
bly deformed.  Contraction  and  deformity  may  be  associated  with  extensive 
peritoneal  adhesions  ;  the  changes  in  size  and  form  being,  then,  in  a  measure 
at  least,  attributable  to  external  pressure. 

The  condition  of  the  liver,  giving  rise  to  hydro-peritoneum,  except  in 
cases  in  which  it  proceeds  from  external  pressure,  is  generally  a  result  of 
the  prolonged  abuse  of  alcoholic  stimulants ;  and  this  result  follows  the 
habitual  drinking  of  spirits,  especially  when  taken  raw,  or  but  little  diluted, 
upon  an  empty  stomach. 

Although  the  spleen  is  enlarged  in  a  certain  proportion  of  cases,  in  con- 
nection with  the  altered  condition  of  the  liver  generally  known  as  cirrhosis, 
there  is  no  ground  for  supposing  that  the  splenic  enlargement  is  a  cause  of 
the  dropsy.  It  may  be  doubted  whether  enlargement  of  the  spleen  alone 
ever  gives  rise  to  hydro-peritoneum. 

Disease  of  the  heart  is  found  too  rarely  associated  with  cirrhosis  of  the 
liver  to  infer  any  relation  of  cause  and  effect  between  the  two  affections. 
When  the  two  are  associated  it  is  probably  a  mere  coincidence.  Coexisting 
disease  of  the  heart,  however,  may  contribute  to  the  dropsy  as  an  auxiliary 
cause.  Existing  independently  of  disease  of  the  liver,  disease  of  the  heart 
gives  rise  to  hydro-peritoneum  only  as  an  element  of  general  dropsy. 

Disease  of  the  kidneys  is  associated  with  cirrhosis  oftener  than  disease 
of  the  heart ;  but  whether  any  relation  of  cause  and  effect  exists  between 
No.  XC.—April  1863.  21 


322  Flint,  Clinical  Report  on  Hydro-Peritoneum.  [April 

the  two  affections,  or  whether  both  proceed  from  the  same  remote  cause  or 
causes,  is  to  be  determined  by  the  analysis  of  a  larger  collection  of  cases. 
Coexisting  disease  of  the  kidneys  may  contribute  indirectly  to  hydro-peri- 
toneum by  inducing  hydrsemia  and  impairing  the  vital  forces.  Existing 
independently  of  disease  of  the  liver,  disease  of  the  kidneys  gives  rise  to 
hydro-peritoneum  only  as  an  element  of  general  dropsy. 

Various  affections,  coexisting  with  cirrhosis  of  the  liver,  such  as  inter- 
mittent fever,  ha3matemesis,  diarrhoea,  may  determine  the  epoch  when  hydro- 
peritoneum  becomes  developed,  or  tend  to  increase  the  dropsical  effusion. 
The  dropsy  may  follow  convalescence  from  some  disease,  such  as  dysentery, 
typhoid  fever,  and  pneumonia.  It  may  occur  during  lactation,  or  shortly 
after  confinement.  The  dropsy,  under  these  circumstances,  is  determined 
or  promoted  in  consequence  of  the  effects  on  the  blood  and  vital  forces. 

Hydro-peritoneum  occurs,  although  very  rarely,  when  not  dependent  on 
cirrhosis  of  the  liver,  or  any  other  incurable  lesions,  cases  ending  in  re- 
covery. The  morbid  condition  or  conditions  on  which  the  dropsy  is  imme- 
diately dependent  in  these  cases  must  be  left  unexplained. 

Hydro-peritoneum  occurs  much  oftener  among  males  than  females.  The 
larger  proportion  of  patients  are  between  30  and  40  years  of  age;  it  occurs 
very  rarely  under  20  or  over  60  years.  Its  causation  is  not  specially 
favoured  by  any  particular  occupation. 

I 

Symptomatology  of  Hydro-peritoneum. — Of  the  important  symp- 
toms which  make  up  the  clinical  history  of  hydro -peritoneum,  the  first 
claiming  notice  are  those  which  relate  to  the  abdomen  and  digestive  sys- 
tem. After  having  considered  these,  the  symptoms  referable  to  other 
anatomical  systems,  viz.,  tegumentary,  circulatory,  urinary,  and  nervous,1 
will  respectively  claim  attention. 

Symptoms  referable  to  the  abdomen  anil  digestive  system. — Abdominal 
pain  rarely  precedes  or  accompanies  the  dropsical  effusion.  In  four  cases  only 
have  I  noted  the  existence  of  pain ;  situated,  in  two  cases,  in  the  right  hypo- 
chondrium,  and  in  the  other  cases  more  diffused.  In  most  of  the  histories 
nothing  is  stated  respecting  this  symptom  ;  but  in  several  the  absence  of 
pain  is  noted.  Transient  colic  pain  would  not  be  deemed  of  sufficient  im- 
portance to  record ;  but  this  is  not  of  frequent  occurrence.  In  one  case  a 
sense  of  soreness  in  the  abdomen  preceded  the  dropsy.  In  none  of  the 
other  cases  is  it  stated  that  soreness,  or  tenderness  on  pressure  existed. 

1  With  respect  to  the  consideration  of  symptoms,  I  wish  to  repeat,  that  several 
of  the  histories  are  incomplete,  the  cases  having  been  only  for  a  time  under  ob- 
servation, and  the  records  sometimes  not  embracing  all  details  even  when  the 
cases  were  observed  during  the  whole  progress  of  the  affection.  The  enumerations 
are  to  be  considered  as  only  approximations  to  accuracy  as  regards  the  frequency 
with  which  the  different  symptoms  occur.  In  view  of  the  fact  just  stated,  I  shall 
devote  but  a  little  space  to  the  symptomatology. 

I 


1863.]         Flint,  Clinical  Report  on  Hydro-Peritoneum.  323 

Patients  sometimes  shrink  when  deep,  strong  pressure  is  made  witlj.  a  view 
to  determine  whether  the  spleen  or  liver  be  enlarged ;  but,  as  a  rule,  no 
more  tenderness  or  soreness  exists  than  is  attributable  to  the  tension  of  the 
abdominal  walls  from  the  pressure  of  the  liquid.  The  absence  of  pain, 
soreness,  and  tenderness,  is  one  of  the  points  in  the  differential  diagnosis 
of  hydro-peritoneum  and  peritonitis  with  effusion.  Another  point  is  the 
absence  of  tension  of  the  abdominal  walls  from  tonic  rigidity  of  the 
muscles.  In  hydro-peritoneum  the  walls  are  tense  only  as  a  result  of  dis- 
tension from  the  amount  of  effused  liquid.  I  may  mention  here  that  pain 
in  the  right  shoulder  is  noted  in  two  cases. 

The  enlargement  of  the  abdomen  from  the  accumulation  of  liquid,  was 
either  great  or  considerable  in  most  of  the  cases.  In  four  cases  only  was 
the  quantity  of  liquid  moderate.  It  may  be  laid  down  as  a  rule  that,  when 
hydro-peritoneum  occurs,  the  dropsical  effusion  almost  invariably  increases 
so  as  to  produce  notable  distension,  and  in  the  large  proportion  of  cases 
the  abdominal  walls  become  more  or  less  tense.  Another  interesting  fact 
with  regard  to  the  effusion  is,  the  rapidity  with  which  it  takes  place.  In 
the  majority  of  cases,  when  the  dropsy  once  commences,  it  goes  on  rapidly, 
and  in  a  short  time  the  abdomen  becomes  considerably  or  greatly  enlarged. 
In  the  abstracts  of  fifteen  of  the  histories  made  for  this  analysis,  the  rapid 
accumulation  of  liquid  is  stated ;  that  is,  considerable  or  great  enlargement 
taking  place  within  a  period  varying  from  two  months  to  a  few  days.  In 
one  case  the  effusion  increased  from  a  moderate  to  a  large  amount  in  the 
course  of  a  few  hours,  occasioning  sudden  dyspnoea  to  such  an  extent  as  to 
require  immediate  tapping ;  and  this  occurred  a  second  time  in  the  same 
case.  I  have  already  alluded  to  the  frequency  with  which  the  dropsical 
effusion  becomes  rapidly  large  in  amount,  as  a  fact  going  to  show  the  co- 
operation of  other  circumstances  than  the  hepatic  obstruction  due  to  the 
structural  lesions  in  cirrhosis,  in  the  causation  of  the  dropsy.  These  lesions 
are  doubtless  slowly  produced,  and  it  is  not  probable  that  they  undergo  a 
sudden  and  rapid  development  at  the  time  when  the  dropsy  occurs  and  is 
rapidly  increasing.  Is  it  not  probable  that,  after  a  certain  amount  of  effu- 
sion has  taken  place,  the  pressure  of  the  liquid  upon  the  liver,  by  adding 
to  the  obstruction  to  the  portal  circulation  in  this  viscus,  increases  the  effu- 
sion? This  question  will  again  come  up  in  connection  with  the  non-occur- 
rence of  effusion,  in  certain  cases,  for  a  greater  or  less  period  after  the 
liquid  has  been  removed  by  tapping. 

It  has  been  seen  that  in  all  the  fatal  cases  but  one  in  which  examinations 
after  death  were  made,  the  liver  was  more  or  less  diminished  in  volume. 
In  the  histories  of  the  remainder  of  the  cases,  fatal  or  non-fatal,  enlarge- 
ment of  the  liver  is  noted  in  two  cases.  In  these  cases  the  lower  margin 
extended  2 £  or  3  inches  below  the  false  ribs,  as  ascertained  by  manual 
examinatfbn  through  the  abdominal  walls.  Enlargement  of  the  liver,  if  the 
abdomen  be  not  greatly  distended,  may  generally  be  ascertained  by  palpa- 


324  Flint,  Clinical  Report  on  Hydro-Peritoneum.  [April 

tion,  and  had  it  existed  in  other  cases  the  fact  would  doubtless  have  been 
noted.  Contraction  of  the  liver,  on  the  other  hand,  cannot  be  so  well 
determined  by  manual  examination.  Is  it  not  determinable  by  percussion  ? 
With  regard  to  the  answer  to  this  question,  I  believe  the  general  impres- 
sion to  be  incorrect.  The  space  between  the  pulmonary  resonance  above 
and  tympanitic  resonance  from  the  transverse  colon  below,  is  supposed  to 
represent  the  vertical  diameter  of  the  liver.  That  this  is  not  so,  is  easily 
demonstrated  in  certain  cases  in  which  enlargement  of  the  liver  is  percep- 
tible by  the  touch.  I  have  been  accustomed  to  point  out  at  the  bedside  a 
discrepancy,  sometimes  of  several  inches,  between  the  positive  evidence 
afforded  by  palpation  of  the  situation  of  the  lower  margin  of  the  liver, 
and  the  apparent  evidence  afforded  by  percussion.  The  tympanitic  reso- 
nance from  the  colon  may  be  propagated  for  a  considerable  space  above 
the  lower  margin  of  the  liver,  and  without  any  appreciable  diminution  of 
intensity.  This  resonance  is  not  reliable  as  evidence  of  the  situation  of 
the  lower  margins  of  the  liver.  The  distance  between  the  pulmonary  and 
tympanitic  resonance  is  only  an  approximation  to  the  vertical  diameter  of 
the  organ.  Not  infrequently  when  the  liver  is  contracted,  the  pulmonary 
and  tympanitic  resonance  almost  and  even  quite  meet.  I  have  for  some 
time  ceased  to  consider  as  accurate  the  measurement  of  the  liver  by  means 
of  percussion. 

The  same  remarks  will  apply  measurably  to  the  spleen.  The  evidence 
afforded  by  tympanitic  resonance  of  the  lower  and  anterior  borders  of  this 
organ  is  unreliable  for  the  same  reason,  viz.,  the  organ  transmits  readily 
tympanitic  resonance.  The  upper  border  of  the  organ  as  well  as  that  of 
the  liver,  is  indicated  by  the  pulmonary  resonance,  which  is  not,  like  the 
tympanitic,  propagated  more  or  less  beyond  the  border.  Enlargement  of 
the  spleen,  if  considerable,  can  generally  be  felt.  Exclusive  of  the  cases 
in  which  examinations  were  made  after  death  (to  which  reference  has 
already  been  made),  this  organ  is  noted  as  enlarged  in  only  one  case. 
Directly  after  tapping,  when  the  abdominal  walls  are  greatly  relaxed,  ex- 
plorations for  the  liver  and  spleen  may  be  made  with  most  facility.  At 
this  time,  the  liver  may  be  felt  to  be  abnormally  hard  and  nodulated  even 
when  contracted,  by  the  fingers  pressed  up  and  under  the  false  ribs. 

Haematemesis  is  noted  in  six  cases.  But  in  three  of  these  cases  it  pre- 
ceded the  development  of  the  dropsy,  and  did  not  recur  afterward.  In  two 
cases  it  occurred  repeatedly.  Both  of  the  latter  cases  were  fatal ;  indeed, 
in  all  these  cases,  save  two,  a  fatal  result  has  taken  place ;  while  the  cases 
under  my  observation  and  the  two  excepted  cases  have  recently  come  under 
observation,  and  will  probably  end  fatally  ere  long.  In  two  of  the  cases 
melaena  also  occurred,  and  in  two  cases  melasna  occurred  without  haemate- 
mesis. Vomiting  (exclusive  of  haematemesis)  is  noted  in  only  two  cases, 
and  in  both  of  these  it  was  a  prominent  symptom.  Diarrhoea  is  noted  as 
a  symptom,  more  or  less  prominent,  in  eight  cases.    On  the  other  hand, 


1863.] 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


325 


constipation  is  noted  in  several  cases;  but  in  the  larger  number  of  cases 
neither  of  these  symptoms  was  present.  *  Diarrhoea  can  hardly  be  regarded 
as  a  favourable  symptom  in  cases  of  hydro-peritoneum ;  in  most  of  the 
cases  in  which  it  occurred,  the  progress  of  the  affection  was  unfavourable. 
It  might  be  deemed  a  priori  a  desirable  event,  so  far  as  the  dropsy  is  con- 
cerned, the  congested  portal  vessels  being  relieved,  in  a  measure,  by  transu- 
dation through  the  intestinal  mucous  membrane ;  the  mode  of  relief,  in 
fact,  being  the  same  as  when  hydragogue  cathartics  are  given.  Clinical 
observation,  however,  shows  not  only  that  diarrhoea  occurs  often er  in  cases 
which  progress  unfavourably  than  in  those  which  pursue  a  favourable 
course ;  but  that  measures  which  succeed  in  relieving  the  diarrhoea  appear, 
sometimes  at  least,  to  exert  a  favourable  effect  on  the  dropsy.  In  one  of 
the  cases  it  is  noted  that  the  dropsy  diminished  notably  after  a  troublesome 
diarrhoea  had  been  relieved  at  one  time  by  bismuth,  and  subsequently  by 
opium. 

Loss  of  appetite  and  disinclination  for  food  existed  in  many  of  the  cases 
while  the  patients  were  under  observation,  and  especially  when  the  disease 
was  progressing  toward  a  fatal  termination.  Some  patients  retained  a 
tolerable  and  some  a  good  appetite.  Generally,  when  the  dropsy  was  suf- 
ficient to  distend  the  abdomen,  patients  complained  of  a  sense  of  fulness 
after  taking  food.  In  several  instances  this  was  a  source  of  complaint 
when  the  abdomen  was  distended,  and,  after  the  liquid  was  removed  by  tap- 
ping, the  patients  were  able  to  eat  freely  without  inconvenience.  In  the 
history  of  one  case  it  is  noted  that  the  gums  were  spongy,  and  hemorrhage 
occurred  in  this  situation  as  in  scorbutus.  The  superficial  veins  of  the 
abdomen  in  most  of  the  cases  were  more  or  less  enlarged.  The  cases  dif- 
fered in  this  regard,  but,  from  a  survey  of  the  histories,  nothing  appears 
to  invest  this  symptom  with  much  importance. 

Symptoms  referable  to  the  integument. — Under  this  head  I  shall  em- 
brace oedema.  And,  as  regards  this  symptom,  the  facts  developed  by  an 
analysis  of  these  cases  conflict  with  certain  commonly  received  opinions. 
More  or  less  oedema  of  the  lower  limbs,  as  is  well  known,  coexists  often 
with  hydro-peritoneum.  But  it  is  supposed  to  follow  the  latter,  and  to  be 
proportionate  to  the  amount  of  abdominal  distension.  In  a  large  propor- 
tion of  these  cases  oedema  of  the  lower  limbs  preceded  the  enlargement  of 
the  abdomen.  Of  twenty-one  cases,  the  histories  of  which  contain  distinct 
information  on  this  point,  in  eleven  oedema  of  the  lower  limbs  had  prece- 
dence. It  has  been  stated  (vide  treatise  by  Dr.  Budd)  that  when  oedema 
of  the  lower  limbs  precedes  the  peritoneal  dropsy,  the  existence  of  cardiac 
or  renal  disease  is  to  be  inferred.  The  facts  developed  by  this  analysis  are 
opposed  to  this  opinion.  Of  the  eleven  cases  in  which  oedema  of  the  lower 
limbs  preceded  the  hydro-peritoneum,  five  were  fatal  and  six  non-fatal.  In 
not  one  of  the  six  non-fatal  cases  was  the  urine  albuminous,  or  were  there 
present  physical  signs  of  disease  of  the  heart.    Autopsies  were  made  in  all 


326  Flint,  Clinical  Report  on  Hydro-Peritoneum,  [April 

of  the  five  fatal  cases.  In  three  of  these  the  heart  and  kidneys  were  found 
to  be  healthy;  in  one  case  old  pericardial  adhesions  existed,  and  the  weight 
of  the  heart  was  14  oz. ;  in  the  other  case  there  was  granular  degeneration 
of  the  kidneys.  In  the  latter  case,  oedema  of  the  face  existed  together 
with  oedema  of  the  lower  limbs ;  but  in  all  the  other  cases,  fatal  and  non- 
fatal, the. oedema  was  confined  to  the  lower  limbs.  It  follows,  from  these 
facts,  that  in  about  one-half  the  cases  in  which  hydro-peritoneum  and  oedema 
of  the  lower  limbs  coexist,  the  latter  precedes  the  former  ;  and  that,  when 
this  is  found  to  be  so,  it  is  not  to  be  inferred  that  the  dropsy  is  associated 
with  renal  or  cardiac  disease.  How  is  this  precedence  of  oedema  to  be 
explained?  The  explanation  which  seems  to  me  probable  is,  that,  in 
addition  to  .the  immediate  cause  of  the  peritoneal  dropsy  (generally  cir- 
rhosis of  the  liver),  other  causes  favouring  dropsical  effusion  exist  in  these 
cases — causes  which  impair  the  condition  of  the  blood,  or  weaken  the 
forces  carrying  on  the  circulation.  I  have  had  occasion  already  to  offer 
this  explanation  in  endeavouring  to  account  for  the  occurrence  of  peritoneal 
dropsy  at  a  particular  epoch,  and  for  the  rapid  increase  of  the  dropsy  after 
it  commences.  It  is  possible  that  a  small  amount  of  abdominal  effusion, 
not  enough  to  produce  any  marked  enlargement  of  the  abdomen,  may 
involve  pressure  on  the  iliac  veins  to  obstruct  the  return  of  blood  from  the 
lower  limbs  sufficiently  to  give  rise  to  the  oedema.  It  is  doubtless  chiefly 
in  consequence  of  this  pressure  and  obstruction  that  oedema  of  the  lower 
limbs  is  produced  in  the  cases  in  which  it  occurs  subsequently  to  the  ab- 
dominal distension.  It  is  worthy  of  note,  that  in  one  of  the  cases  in  which 
oedema  of  the  lower  limbs  preceded  the  hydro-peritoneum,  it  disappeared 
after  the  latter  had  become  developed. 

(Edema  of  the  face,  upper  extremities  and  chest,  in  other  words,  anasarca, 
does  not  belong  to  the  clinical  history  of  simple  hydro-peritoneum.  Of 
thirty-nine  cases,  in  the  histories  of  which  information  on  this  point  is  con- 
tained, anasarca  existed  in  only  four ;  and  in  each  of  these  four  cases  save  one, 
the  oedema  of  the  upper  part  of  the  body  was  slight.  In  each  of  these 
cases  either  cardiac  or  renal  disease  existed,  to  wit,  in  the  disease  of  the 
kidneys  alone,  in  one  mitral  lesion  and  enlargement  of  the  heart  alone,  and 
in  one  old  pericardial  adhesion,  together  with  disease  of  the  kidneys.  In 
some  of  the  cases  in  which  the  oedema  was  limited  to  the  lower  part  of  the 
body,  the  swelling  of  the  limbs  was  very  great,  extending  also  sometimes 
to  the  genital  organs.  The  appearance  of  the  patient  in  these  cases  pre- 
sented a  remarkable  disproportion  between  the  lower  limbs  with  the  abdo- 
men and  the  upper  part  of  the  body — the  latter  greatly  emaciated,  and  the 
former  enormously  enlarged.  But  in  these  cases  the  heart  and  kidneys  are 
usually  free  from  disease.  The  existence,  however,  of  oedema  in  the  upper 
part  of  the  body,  i.  c,  in  the  face,  upper  limbs,  or  over  the  sternum,  is 
evidence  of  coexisting  disease  of  the  heart  or  the  kidneys,  or  of  both  these 
organs. 


^1863.]         Flint,  Clinical  Report  on  Hydro-Peritoneum.  321 

Hydro-peritoneum,  even  when  the  abdominal  distension  is  great,  is  not 
always  accompanied  by  oedema.  In  nine  cases  oedema  did  not  exist  while 
the  cases  were  under  my  observation  ;  and  in  some  of  these  cases  the  abdo- 
men was  greatly  enlarged  by  the  amount  of  dropsical  effusion. 

Cholaemia  or  icterus  may  be  included  under  this  head.  This  symptom  is 
rarely  present  in  cases  of  hydro-peritoneum.  Of  the  46  cases  it  is  noted  in 
the  histories  of  1 ;  and  in  one  of  these  cases  it  preceded,  but  did  not 
accompany,  the  dropsy.  It  is  not  a  symptom  of  favourable  omen.  Of 
the  T  cases,  6  ended  fatally  under  my  observation.  In  none  of  the  cases 
was  the  yellowness  of  the  conjunctiva  and  skin  intense,  but  it  was  slight  in 
all,  and  in  the  non-fatal  cases  it  was  extremely  slight.  The  rare  occurrence 
of  jaundice  in  cases  of  hydro-peritoneum  dependent  on  cirrhosis,  is  one  of 
the  facts  going  to  show  that  the  bile  pigment  is  a  product  of  the  secretion 
of  the  liver,  not  preformed  in  the  blood,  and  that  the  yellowness  of  the 
tissues  denotes  the  resorption  of  bile.  In  certain  of  the  cases  of  cirrhosis 
in  which  the  liver  is  greatly  contracted  and  deformed,  the  secretory  func- 
tion of  the  organ  must  be  impaired  to  a  considerable  extent ;  and  jaundice 
would  be  expected  to  occur  frequently,  instead  of  very  rarely,  if  this  symp- 
tom depended  on  the  accumulation  in  the  blood  of  bile  pigment  in  conse- 
quence of  its  non-secretion  by  the  liver. 

Pallor  of  the  prolabia  and  skin,  denoting  anaemia,  existed  more  or  less 
in  the  great  majority  of  the  cases.  Some  of  the  cases  were  characterized 
by  a  marked  anaBmic  aspect.  In  general,  this  aspect  was  marked  in  pro- 
portion as  other  symptoms  showed  the  condition  of  the  patient  to  be 
unfavourable  as  regards  recovery  or  improvement.  This  symptom,  associ- 
ated with  other  symptoms  which  have  been  considered,  gives  rise  to  appear- 
ances which  are  diagnostic  and  striking,  viz.,  pallor  of  the  countenance, 
emaciation  of  the  face  and  upper  extremities,  distension  of  the  abdomen, 
with  enlarged  superficial  veins,  and  oedema  of  the  lower  extremities.  When 
this  group  of  appearances  is  presented,  a  glance  suffices  to  determine  the 
disease,  and  the  hopeless  condition  of  the  patient. 

Symptoms  referable  to  the  circulation. — The  coexistence  of  disease  of 
the  heart  has  been  already  considered.  I  have  only  to  notice,  under  this 
head,  the  condition  of  the  circulation  as  represented  by  the  pulse.  The 
state  of  the  pulse  is  noted  in  25  cases.  But  as  the  histories  consist  of 
notes  made  at  irregular  intervals,  and  in  many  of  the  cases  do  not  embrace 
the  whole  duration  of  the  disease,  I  have  not  data  for  determining  the 
variations  as  regards  this  symptom,  at  different  periods  in  the  same  case. 
The  facts  which  were  noted  show  the  absence  of  febrile  movement  in  cases 
of  hydro-peritoneum,  except  there  be  some  superadded  or  intercurrent 
affection.  In  some  cases  the  pulse  was  not  accelerated ;  in  other  cases  it 
was  more  or  less  frequent.  It  was  generally  small,  soft,  and  feeble.  When 
frequent,  the  frequency  was  of  that  kind  which  denotes  diminution  of  the 
vital  forces  or  asthenia.    A  notably  small,  frequent,  and  feeble  pulse  in 


328  Flint,  Clinical  Report  on  Hydro -Peritoneum.  [April 

this  affection  may  be  considered  as  evidence  that  the  case  is  advancing 
toward  a  fatal  termination. 

Symptoms  referable  to  the  urinary  system. — My  records  contain  very 
little  respecting  the  urine  beyond  the  presence  or  absence  of  albumen.  As 
regards  albuminuria,  the  facts  have  been  already  stated.  It  is  noted  fre- 
quently that  the  quantity  of  urine  was  small ;  but  in  several  cases  it  was 
abundant.  A  large  increase,  occurring  always  after  tapping,  is  noted  in 
one  case  in  which  the  abdomen  was  punctured  thirty  times.  In  one  case  the 
urine  was  habitually  of  a  bright  vermilion  colour  as  if  it  contained  blood. 
The  microscope,  however,  showed  absence  of  the  red  globules,  and  no  albu- 
men was  present.  The  urates  were  very  abundant  in  this  case,  the  deposit 
being  of  the  same  colour  as  the  liquid.  The  appearances  corresponded 
with  those  described  by  Golding  Bird  as  belonging  to  purpurine.  Without 
a  microscopical  examination,  the  colour  might  be  considered  as  denoting 
hematuria.  Had  a  similar  condition  of  the  urine  existed  in  any  of  the 
other  cases  while  they  were  under  my  observation,  it  could  hardly  have 
failed  to  attract  attention,  and  would  have  been  noted. 

Symptoms  referable  to  the  nervous  system. — In  the  great  majority  of 
cases  no  important  phenomena  pertaining  to  the  nervous  system  are 
noted.  The  mode  of  dying  is  usually  by  slow  asthenia ;  if,  however,  the 
accumulation  of  liquid  be  very  great,  or  if  it  take  place  very  rapidly,  death 
may  be  due  to  the  extent  to  which  the  respiratory  function  is  compromised. 
The  mental  functions  are  generally  preserved  up  to  the  last  moments  of 
life.  To  the  latter  rule  there  are  occasional  exceptions.  In  three  cases  I 
have  noted  the  occurrence  of  delirium  several  days  before  death.  In  one 
case  the  delirium  was  hilarious;  in  one  case  the  patient  appeared  bewildered, 
and  in  one  case  the  patient  lapsed  from  childishness  into  imbecility.  These 
cases  ended  in  coma.  In  three  other  cases  the  patients  died  comatose.  In 
one  case  convulsions  occurred  followed  by  coma. 

These  few  facts  are  all  which  I  have  noted.  It  is  certain  that  notable 
disturbance  of  the  nervous  system  does  not  occur  until  the  affection  ap- 
proaches a  fatal  termination.  What  is  the  rationale  of  the  delirium, 
coma,  and  convulsions  which  are  sometimes  observed  ?  This  is  an  interest- 
ing inquiry.  My  facts  do  not  enable  me  to  answer  it.  These  phenomena 
may  arise  from  the  retention  of  the  blood  of  the  excretory  principles 
contained  in  the  bile.  Cholesterine  is  doubtless  one  of  these  excretory 
principles ;  and  perhaps  there  are  others  not  yet  observed.  Here  is  a  rich 
field  for  clinical  research.  The  distinctive  features  of  cholestersemia  have 
not  as  yet  been  ascertained.  I  have  been  led  to  suspect  that  this  kind  of 
blood-poisoning  occurs  especially  in  certain  cases  of  fatty  liver.  But  the 
coexistence  of  disease  of  the  kidney  may  explain  the  occurrence  of  the 
nervous  phenomena  just  mentioned.  It  is  a  question  to  be  settled  by  an 
accumulation  of  facts  whether  these  phenomena  are  due  to  uraemia,  or 


1863.] 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


329 


to  the  non-elimination  of  biliary  principles,  or  to  both  these  pathological 
conditions. 

Management  of  Hydro-peritoneum. — In  the  management  of  hydro- 
peritonenm  a  prime  object  is  to  effect  the  removal  or  diminution  of  the 
peritoneal  effusion.  This  object  is  important  in  proportion  to  the  distress 
and  danger  arising  from  the  amount  of  effusion.  It  is  desirable,  however, 
when  the  amount  is  not  great  enough  to  occasion  distress  or  danger. 
There  is  no  foundation  for  the  idea  that  the  pressure  of  a  certain  quantity 
of  liquid  tends  to  restrain  further  effusion;  on  the  contrary,  clinical  obser- 
vation shows  rather  a  tendency  of  the  pressure  of  liquid  to  accelerate  the 
progress  of  the  dropsy.  Whether  the  quantity  be  large  or  moderate,  there- 
fore, its  removal  or  diminution  is  a  therapeutic  indication.  The  means  for 
effecting  the  object  are  either  direct  or  indirect.  It  is  effected  directly  by 
tapping,  and  it  may  be  effected  indirectly  by  measures  which  increase  the 
density  of  the  blood  by  lessening  the  proportion  of  water,  and  thereby  fa- 
vouring the  endosmosis  or  absorption  of  the  dropsical  effusion.  The  mea- 
sures for  this  purpose  are  diuretic  remedies  and  hydragogue  cathartics. 
These  will  claim  separate  consideration. 

Diuretic  Remedies. — In  13  of  my  cases  diuretics  were  employed  to  a 
greater  or  less  extent.  In  8  of  these  13  cases  no  effect  upon  the  dropsy 
was  produced,  the  amount  of  liquid  either  remaining  stationary  or  increas- 
ing. The  quantity  of  urine  was  much  increased  in  2  cases,  the  quantity  in 
the  other  cases  being  either  slightly  increased  or  unaffected.  Five  of  these 
8  cases  ended  fatally  under  my  observation.  In  5  of  the  13  cases,  improve- 
ment, as  regards  the  dropsical  effusion,  took  place  under  the  use  of  diu- 
retics. In  2  of  these  5  cases  the  dropsy  diminished  under  the  use  of  diu- 
retics given  for  a  short  period,  but  the  diminution  was  not  less  after  the 
diuretics  were  discontinued,  and  a  tonic  remedy  substituted.  In  two  cases 
the  diuretics  constituted  the  whole  treatment,  and  the  improvement  was 
progressive  and  marked.  In  one  case  after  tapping  the  patient  took  a  so- 
lution of  the  bi-tartrate  and  the  nitrate  of  potassa,  with  digitalis,  for  ten 
weeks,  and  during  this  period  there  was  no  return  of  the  dropsy.  In  this 
case  a  purge  of  calomel  and  jalap  was  given  weekly,  and  the  diet  consisted 
mainly  of  toast  and  cider.  This  plan  of  treatment  was  recommended  by 
some  one  not  connected  with  the  hospital,  and  adopted  by  the  patient  with 
my  consent.  At  the  end  of  ten  weeks  the  dropsy  reappeared,  and  the  case 
ended  fatally.  It  is  to  be  added  that  during  the  ten  weeks  of  exemption 
from  dropsy,  the  quantity  of  urine  was  small. 

The  diuretic  remedies  used  were  as  follows :  nitrate  of  potassa  alone  in 
3  cases;  do.  with  bi-tartrate  of  potassa  in  1  case;  squill,  juniper  and  the 
nitrate  of  potassa  in  1  case;  nitrate  and  bi-tartrate  of  potassa  and  digitalis 
in  1  case ;  bi-tartrate  of  potassa  in  2  cases ;  acetate  of  potassa  in  1  case ; 
digitalis  and  squill  in  1  case ;  bi-tartrate  of  potassa,  squill,  digitalis  and 


330 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


[April 


blue  mass  in  1  case ;  bi-tartrate  of  potassa  and  digitalis  in  1  case;  and 
in  1  case  the  diuretic  remedy  is  not  noted.  In  the  5  cases  in  which  im- 
provement took  place  under  the  use  of  diuretics,  the  remedies  were  as  fol- 
lows :  nitrate  of  potassa  in  2  cases ;  nitrate  and  bi-tartrate  of  potassa  with 
digitalis  in  1  case ;  bi-tartrate  of  potassa  with  squill,  digitalis  and  blue 
mass  in  1  case,  and  the  acetate  of  potassa  in  1  case.  Squill,  iodine  and 
digitalis  were  used  by  means  of  external  application  in  2  cases,  but  with 
little  or  no  effect. 

These  facts  by  no  means  afford  much  evidence  of  the  efficacy  of  diuretics 
in  the  management  of  hydro-peritoneum ;  they  render  it  probable,  however, 
that,  while  in  the  majority  of  cases  no  benefit  is  derived  from  these  reme- 
dies, in  some  cases  they  contribute  to  the  object  under  consideration.  This 
conclusion  I  suppose  to  be  in  accordance  with  the  views  generally  held  by 
physicians.  The  difficulty  of  exciting  the  action  of  the  kidneys  in  this 
affection  is,  in  part  at  least,  explicable.  Obstruction  to  the  passage  of  the 
portal  blood  into  the  general  circulation  (which  occasions  the  dropsy), 
prevents  the  free  transportation  of  the  remedies  to  the  kidneys!  Moreover, 
the  pressure  of  the  effused  liquid  on  the  vessels  connected  with  the  kid- 
neys, and  also  on  the  kidneys,  lessens  their  functional  activity.  As  proof 
of  this,  the  quantity  of  urine  is  observed  to  increase  notably  in  some  cases 
immediately  after  tapping. 

With  respect  to  the  employment  of  diuretics,  an  important  consideration 
is,  they  may  be  tried  with  entire  safety,  if  properly  prescribed  and  not  con- 
tinued too  long,  since  they  do  not  cause  much  perturbation  nor  exhaust 
the  vital  powers. 

Hydragogue  Cathartics. — Hydragogues,  in  doses  sufficient  to  produce 
abundant  liquid  dejections,  entered  into  the  treatment  in  seventeen  cases. 
Elaterium  is  noted  as  the  remedy  employed  in  all  save  two  cases,  in  which 
the  articles  used  are  not  stated.  It  was  probably  employed  in  the  latter 
cases  also.  Seven  of  these  cases  are  among  the  fatal,  and  an  equal  number 
among  the  non-fatal,  cases.  In  nine  of  the  seventeen  cases  no  appreciable 
benefit  was  derived  from  this  treatment.  In  the  remaining  eight  cases  the 
results  were  as  follows  : — 

Case  1. — The  dropsical  effusion  was  diminished,  but  otherwise  no  im- 
provement.   This  case  ended  fatally. 

Case  2. — Diminution  of  dropsy,  but  otherwise  no  benefit.    A  fatal  case. 

Case  3. — Dropsy  diminished,  but  subsequently  diuretics  were  substitut- 
ed, and  general  improvement  under  the  use  of  the  latter. 

Case  4. — Diminution  of  dropsy ;  subsequently  convulsions  and  sudden 
death. 

Case  5. — Diminution  of  dropsy ;  subsequently  diuretics,  and  removal  of 
the  effusion. 

Case  6. — Diminution  of  dropsy,  and  temporary  general  improvement ; 
subsequently  elaterium  was  repeated  without  benefit. 

Case  7. — Immediate  and  almost  complete  removal  of  the  dropsy,  but  it 


1863.] 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


331 


shortly  returned,  and  the  remedy  occasioned  so  much  exhaustion  that  it 
was  not  repeated.    Subsequently  this  patient  completely  recovered. 

Case  8. — Marked  diminution  of  the  dropsy,  but  it  returned  and  increased 
when  the  hydragogues  were  discontinued. 

These  results  contain  very  little  evidence  in  behalf  of  the  usefulness  of 
hydragogue  cathartics  in  hydro-peritoneum.  The  dropsy,  in  some  cases, 
is  diminished  by  their  use,  and  in  a  small  proportion  of  cases  the  diminu- 
tion is  marked.  But,  generally,  little  is  accomplished,  and  that  little  only 
for  a  brief  period.  Owing  to  the  disturbance  and  prostration  caused  by 
their  prolonged  use,  they  cannot  be  continued  long  enough  to  effect  the 
object,  even  when  we  might  hope  that,  if  borne,  they  might  prove  effectual. 
In  the  majority  of  cases,  if  continued,  or  often  repeated,  they  do  harm,  rather 
than  good.  In  short,  I  believe  that,  as  a  rule,  they  should  not  enter 
largely  into  the  treatment. 

As  one  of  the  indirect  means  of  effecting  the  removal  or  diminution  of 
the  dropsical  effusion,  restriction  of  the  amount  of  ingested  liquids  is  to  be 
mentioned.  This  is  important  in  conjunction  with  other  indirect  means, 
or  with  the  direct  method  of  treatment.  The  addition  of  water  to  the 
blood  is  to  be  limited  as  far  as  practicable,  and,  for  this  end,  patients 
should  be  enjoined  to  take  no  more  drink  of  any  kind  than  \s  consistent 
with  a  due  regard  to  the  parts  of  the  economy.  This  part  of  the  manage- 
ment is  often  imperfectly  carried  out,  because  many  patients  lack  the 
necessary  determination  and  perseverance  to  conform  to  our  injunctions. 

Tapping. — In  twenty  of  the  forty-six  cases  tapping  was  resorted  to.  Of 
these  twenty  cases,  eight  are  among  those  which  proved  fatal  under  my 
observation.  The  operation  was  performed  but  once  in  eleven  cases  ;  thrice 
in  four  cases ;  four  times  in  one  case ;  six  times  in  one  case ;  repeatedly 
(the  number  of  times  not  stated)  in  two  cases,  and  thirty  times  in  one 
case.  As  the  propriety  of  the  operation  is  a  point  of  much  practical  im- 
portance, I  shall  present  briefly  the  facts  bearing  upon  its  influence  on  the 
affection  in  all  of  the  twenty  cases. 

In  five  of  the  cases  the  patients  were  tapped  within  a  few  weeks  or  days 
of  the  date  of  death.  The  operation  in  all  these  cases,  save  one,1  was  per- 
formed for  the  sake  of  immediate  relief,  without  any  expectation  of  per- 
manent benefit.  Immediate  relief  followed  in  all  the  cases.  There  is  no 
reason  to  think  that  life  was  shortened  in  any  of  the  cases ;  but,  on  the 
contrary,  it  was,  probably,  in  some  at  least,  prolonged  by  the  operation. 
Fatal  prostration  or  sinking  did  not  occur  in  any  instance.  In  the  re- 
mainder of  the  fatal  cases  the  facts  were  as  follows  : — 

Case  1. — The  patient  was  tapped  six  times  in  the  course  of  two  months, 

1  In  the  excepted  case  there  was  no  return  of  the  dropsy  at  the  end  of  three 
weeks,  and  the  patient  seemed  quite  well.  Death  occurred  in  this  case  instantly 
while  the  patient  was  conversing  cheerfully,  and  the  cause  of  the  sudden  death 
was  not  ascertained. 


332 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


[April 


and  was  then  removed  by  his  friends  from  the  hospital  in  order  to  escape 
a  post-mortem  examination.    He  died  shortly  after  leaving  the  hospital. 

Case  2. — Tapping  was  performed  twice  in  three  weeks.  After  the 
second  tapping  there  was  no  return  of  the  dropsy  for  ten  weeks,  and  the 
patient  improved  greatly  in  appearance  and  strength.  During  this  ten 
weeks  the  patient  took  daily  small  doses  of  the  nitrate  and  bi-tartrate  of 
potassa.  He  was  purged  once  a  week  with  calomel  and  jalap,  and  his  diet 
was  toast  and  cider.  At  the  end  of  the  ten  weeks  the  dropsy  returned,  and 
he  died  shortly  afterward.  The  autopsy  in  this  case  revealed  a  contracted 
hob-nailed  liver. 

Case  3. — The  tapping  was  repeatedly  performed  during  the  last  five 
months  of  life.  The  immediate  relief  was  marked,  but  the  liquid  speedily 
reaccumulated. 

Case  4. — The  tapping  was  performed  twice  during  the  last  two  months 
of  life  with  immediate  relief,  but  the  dropsy  soon  returned. 

The  facts  in  ten  non-fatal  cases  were  as  follows  : — 

Case  1. — Tapped  repeatedly  during  five  months,  and,  when  last  seen, 
the  abdomen  was  distended  with  liquid,  and  there  existed  much  emaciation 
and  debility. 

Case  2. — Tapped  with  great  immediate  relief.  Liquid  flowed  from  the 
puncture  for  several  days.  Twenty-two  days  afterwards  the  patient  had 
no  reaccumu^tion  of  liquid,  and  was  discharged  from  the  hospital. 

Case  3. — Tapped,  and  liquid  flowed  from  the  puncture  for  several  days. 
Four  months  afterward,  when  last  seen,  there  had  been  no  return  of  the 
dropsy,  and  the  patient  reported  quite  well. 

Case  4. — Tapped  with  great  relief.  Three  months  afterward,  when  last 
seen,  no  return  of  dropsy ;  the  patient  reporting  and  looking  well. 

Case  5. — Tapped  twice  in  course  of  three  or  four  months.  Subsequent 
history  not  known. 

Case  6. — Tapped,  for  the  first  time,  eighteen  months  before  the  case 
came  under  my  observation.  Prior  to  the  dropsy  the  patient  had  haemate- 
mesis.  The  dropsy  had  existed  for  two  or  three  months  before  the  first 
operation,  and  had  been  once  removed  by  hydragogue  cathartics.  In  the 
course  of  eighteen  months  tapping  was  repeated  thirty  times.  The  patient 
had  come  to  regard  the  operation  as  a  trivial  affair,  and  the  day  after  its 
performance  was  accustomed  to  go  about  as  usual.  When  I  saw  him  he 
was  able  to  take  pretty  active  exercise,  but  was  quite  ansemic  ;  the  abdomen 
was  then  filled,  and  the  abdominal  veins  largely  dilated.  The  subsequent 
history  is  not  known. 

Case  7. — The  patient,  when  admitted  into  hospital,  was  greatly  pros- 
trated, and  tapping  was  resorted  to  when  the  case  seemed  to  be  near  a  fatal 
ending.  The  immediate  relief  was  marked,  and  the  patient's  life  appeared 
to  be  saved  by  the  operation.  Improvement  was  progressive,  but  after  a 
month  the  abdomen  filled  rapidly,  and  tapping  was  again  employed.  The 
operation  was  repeated  twice  during  the  following  month,  and  the  patient 
then  left  the  hospital  extremely  feeble. 

Case  8. — Tapped  six  months  ago,  and  up  to  the  present  time  there  has 
been  no  return  of  the  dropsy.    The  health  of  the  patient  is  now  good. 

Case  9. — Tapped  a  few  weeks  ago,  and  the  dropsy  is  now  returning. 

Case  10. — Tapped  quite  recently  with  marked  immediate  relief. 

From  the  foregoing  facts  I  draw  the  following  conclusions :    1.  Tap- 


1863.] 


Flint,  Clinical  Report  on  Hydro -Peritoneum. 


333 


ping  may  be  resorted  to  as  a  palliative  measure  when  the  condition  of  the 
patient  is  such  that  only  temporary  relief  is  to  be  expected.  We  need  not 
be  deterred  from  the  operation  by  the  debility  of  the  patient.  So  far  as 
these  facts  are  concerned,  they  afford  no  support  to  the  notion  that  remov- 
ing the  liquid  will  tend  to  produce  exhaustion  in  consequence  of  more  rapid 
subsequent  effusion.  On  the  contrary,  life  appears  to  be  prolonged  by  the 
operation  under  these  circumstances.  2.  In  a  certain  proportion  of  cases 
the  dropsy  returns  more  or  less  quickly,  and  if  this  plan  of  treatment  be 
adopted,  it  may  be  necessary  to  repeat  the  operation  many  times.  The 
repetitions,  however,  are  innocuous.  Of  this,  the  case  in  which  it  was  per- 
formed thirty  times  in  18  months  is  a  striking  illustration.  3.  In  some 
cases  the  dropsy  does  not  return  for  a  considerable  and  even  a  long  period 
after  the  operation.  Of  this  No.  2  of  the  fatal,  and  Nos.  3,  4  and  8  of  the 
non-fatal,  cases  are  examples,  the  dropsy  in  the  first  case  not  returning  for 
ten  weeks,  and  in  the  other  three  cases  not  having  returned  at  the  end  of 
4,  3  and  6  months. 

As  regards  the  employment  of  tapping,  the  views  inculcated  by  medical 
writers  and  generally  entertained  are,  that  it  is  to  be  resorted  to  only  when 
the  abdominal  distension  occasions  great  distress  or  danger,  and  not  until 
the  indirect  means  of  diminishing  the  effusion  have  been  thoroughly  tried  ; 
that  the  effusion  generally  goes  on  more  rapidly  after  the  liquid  has  been 
removed  by  puncture,  than  while  it  was  allowed  to  remain,  or  when  it  is 
lessened  by  diuretics  and  hydragogue  cathartics,  and  that  the  operation 
involves  danger  if  the  system  be  much  prostrated.  I  have  been  led  to  be- 
lieve that  these  views  are  erroneous.  By  tapping  we  effect  promptly,  with- 
out perturbation  and  without  impairing  the  vital  powers,  the  same  object 
which  -^e  strive  to  accomplish  by  indirect  means  when  we  employ  diuretics 
and  hydragogue  cathartics,  measures  which  are  generally  ineffectual,  which 
disturb  the  digestive  functions,  and  enfeeble  the  powers  of  life.  The  opera- 
tion is  trivial,  and  involves  little  or  no  risk  of  accidents  or  of  peritoneal  in- 
flammation. There  is  no  danger  from  increased  rapidity  of  effusion  directly 
after  the  operation.  The  patient  is  spared  not  only  the  inconvenience  and 
distress,  but  the  permanent  injury  caused  by  the  prolonged  pressure  of  the 
liquid  upon  the  abdominal  and  thoracic  viscera,  and  he  is  in  a  condition 
more  favourable  for  other  remedies  than  those  which  have  special  reference 
to  the  removal  or  diminution  of  the  dropsy.  Clinical  experience  shows 
that  in  some  cases,  even  when  the  dropsy  is  dependent  on  cirrhosis,  the 
liquid  does  not  accumulate  for  weeks  and  months  after  the  operation.  It 
remains  to  be  ascertained  if  in  any  cases  in  which  it  has  not  yet  returned, 
the  exemption  will  prove  to  be  permanent.  A  larger  accumulation  of  cases 
in  which  the  operation  was  resorted  to  early  is  desirable;  but  upon  rational 
grounds  and  with  my  present  amount  of  experience,  it  seems  to  me  judi- 
cious to  resort  to  tapping  so  soon  as  the  accumulation  of  liquid  is  sufficient 
to  occasion  much  inconvenience,  adopting  this  direct  method  in  lieu  of  the 


334  Flint,  Clinical  Report  on  Hydro-Peritoneum.  [April 

indirect  means,  provided  the  latter  do  not  happen  to  prove  immediately 
efficacious,  and  repeating  the  operation  whenever  the  abdomen  becomes 
again  distended  to  the  same  extent. 

The  management  of  hydro-peritoneum  involves  measures  other  than  those 
which  relate  specially  to  the  object  thus  far  considered,  viz.,  the  removal  or 
diminution  of  the  dropsical  effusion.  In  studying  my  cases  with  reference 
to  causation,  I  was  led  to  conclude  that  the  dropsy  is  often  measurably  due 
to  causes  which  are  remotely  operative,  that  is,  causes  co-operating  with 
the  pathological  condition  on  which  the  dropsy  is  immediately  dependent. 
These  remote  or  accessory  causes  act  by  impoverishing  the  blood,  and  im- 
pairing the  forces  which  carry  on  the  circulation.  We  may  be  able  to 
control  these  causes  and  remove  their  effects,  although  the  immediate  cause 
of  the  dropsy  be  beyond  our  control.  The  latter  may  not  alone  be  sufficient 
to  perpetuate  the  dropsy,  when  divested  of  the  remote  or  accessory  causes. 
Here,  then,  is  an  important  part  of  the  management.  And  the  first  point 
relates  to  the  habit  of  spirit  drinking.  This  being  the  special  cause  of  the 
lesion  which  is  the  proximate  pathological  condition  in  the  majority  of 
cases  (cirrhosis),  the  abatement  of  this  cause  will  be  likely  to  prevent  the 
further  progress  of  the  lesion.  But,  aside  from  this  result,  the  habit  of 
spirit  drinking  favours  the  occurrence  of  dropsy  by  disturbing  the  digestive 
system,  and  inducing  general  debility.  I  shall  presently  cite  two  cases  in 
which  the  interruption  of  this  habit  was  alone  or  chiefly  sufficient  for  the 
disappearance  of  the  dropsy.  If  the  patient  be  not  much  debilitated,  it  is 
perhaps  best  that  alcohol  in  any  form  be  abstained  from  ;  but  if  sustaining 
measures  are  called  for,  wine  or  malt  liquors  should,  if  practicable,  take  the 
place  of  spirit ;  and  if  the  interdiction  of  the  latter  cannot  be  enforced,  the 
importance  of  not  taking  it  upon  an  empty  stomach  should  be  impfessed. 

Tonic  remedies  have  appeared  to  me  to  be  useful  in  the  management  of 
hydro-peritoneum.  The  citrate  of  iron  and  quinia  is  the  remedy  which  I 
have  almost  universally  given.  In  seven  of  my  cases  the  histories  render 
it  probable  that  this  remedy  contributed  to  the  improvement  which  took 
place.  The  facts  bearing  on  the  supposed  utility  of  this  remedy  in  these 
cases  are  as  follows  : — 

Case  1. — The  patient  was  discharged  from  hospital  free  from  dropsy, 
and  reporting  well  enough  to  return  to  work ;  the  medicinal  treatment 
having  consisted  of  the  citrate  of  iron  and  quinia,  with  the  exception  of  a 
diuretic  for  ten  days. 

Case  2. — Precisely  the  same  facts,  only  the  diuretic  was  continued  but 
nine  days. 

Cake  3. — After  free  purging  with  elaterium,  the  only  remedy  employed 
was  the  citrate  of  iron  and  quinia.  Under  this  remedy  there  was  marked 
improvement,  and  the  patient  reported  well  enough  to  be  discharged,  but 
he  was  not  entirely  free  from  the  dropsy. 

Case  4. — No  therapeutic  measures  were  employed,  save  the  use  of  the 
citrate  of  iron  and  quinia.  The  patient  was  discharged  from  hospital  free 
from  dropsy. 


1863.] 


Flint,  Clinical  Report  on  Hydro-Peritoneum. 


335 


Case  5. — Great  improvement,  the  dropsy  having  nearly  disappeared 
when  the  patient  was  last  seen.  And  in  this  case  the  quinia  and  iron,  and 
the  tincture  of  sesquichloride  of  iron,  with  bismuth  and  opium  for  diarrhoea, 
constituted  the  treatment. 

Case  6. — After  tapping,  the  citrate  of  iron  and  quinia  constituted  the 
treatment.  Patient  discharged  from  hospital  free  from  dropsy,  and  quite 
well,  four  months  after  the  tapping. 

Case  T. — The  dropsy  disappeared  in  a  few  weeks,  without  tapping,  under 
the  use  of  the  citrate  of  iron  and  quinia;  neither  diuretics  nor  hydragogues 
having  been  given,  and  the  patient  remained  free  from  the  dropsy  when 
last  seen,  two  months  after  coming  under  observation. 

We  cannot  estimate,  in  these  cases,  the  importance  to  be  attached  to  the 
interruption  of  the  habit  of  spirit-drinking,  and  to  better  hygienic  condi- 
tions in  hospitals  than  those  to  which  the  patients  may  have  been  pre- 
viously accustomed.  It  is  fair  to  presume  that  the  tonic  medication  was 
not  without  some  effect.  I  should,  perhaps,  speak  more  confidently  of  its 
value,  were  it  not  that  improvement  and  recovery  may  take  place  under 
hygienic  treatment  without  any  medication.  Of  this  my  cases  furnish  the 
two  following  illustrations  : — 

Case  1... — The  patient  was  admitted  into  hospital  a  month  after  the 
dropsy  commenced.  The  abdomen  was  greatly  distended.  He  was  at  first 
purged  with  elaterium,  but  as  the  purging  was  not  followed  by  any  reduc- 
tion of  the  dropsy,  and  occasioned  much  prostration,  this  remedy  was  not 
repeated,  and  a  quarter  of  a  grain  of  the  extract  of  belladonna,  three  times 
daily,  was  prescribed  as  a  placebo.  I  intended  to  resort  to  tapping,  but 
the  operation  was  deferred  for  several  days,  and,  in  the  meantime,  there 
was  distinct  general  improvement  with  diminution  of  the  size  of  the  abdo- 
men. The  dropsy  rapidly  disappeared,  and  in  a  short  time  he  reported 
well  enough  to  return  to  work  and  was  discharged.  The  extract  of  bella- 
donna was  the  only  remedy  employed  in  this  case. 

Case  2. — This  case  has  been  already  given  (case  of  Mrs.  W.,  vide  page 
319)  as  an  illustration  of  complete  recovery,  the  patient  having  been  in 
excellent  health  for  more  than  eighteen  months.  After  the  employment 
of  elaterium,  iodide  of  potassium  and  the  citrate  of  iron  and  quinia,  the 
dropsy  remaining  unaffected,  she  recovered  on  going  into  the  country  and 
taking  oat-door  exercise,  all  medication  having  been  suspended. 

Of  the  use  of  mercury  in  hydro-peritoneum  I  can  say  nothing  from  my 
own  experience.  In  some  of  my  cases  mercurialization  had  been  produced, 
prior  to  their  coming  under  my  care,  without  any  benefit.  I  should  expect 
only  injury  from  a  remedy  which  induces  anaemia. 

In  cases  in  which  diarrhoea  exists,  a  practical  point  relates  to  the  pro- 
priety of  endeavouring  to  relieve  this  symptom.  Does  not  its  continuance 
tend  to  lessen  the  dropsy  ?  It  is  generally  supposed  to  have  this  effect, 
and  therefore  its  continuance  is  regarded  as  desirable.  I  have  been  led  to 
doubt  the  correctness  of  this  opinion,  and  to  think  that,  in  some  cases-  at 
least,  by  increasing  the  general  debility,  diarrhoea  contributes  to  the  increase 
of  the  dropsy.   In  one  of  my  cases  the  patient  was  progressively  improving 


336  Flint,  Clinical  Report  on  Hydro-Peritoneum.  [April 

under  tonic  medication,  but  was  troubled  with  chronic  diarrhoea,  and  I 
resolved  to  see  what  would  be  the  consequence  of  arresting  the  diarrhoea. 
Bismuth,  and  afterward  opium,  were  prescribed  for  this  end,  and  proved 
effectual.  The  improvement  in  this  case  was  not  less  progressive  after  the 
diarrhoea  was  arrested  than  before. 

Another  practical  point  relates  to  the  treatment  of  oedema  of  the  genital 
organs  by  scarification.  The  oedema  in  this  situation  sometimes  becomes 
excessive,  but  the  parts  cannot  be  scarified  without  risk  of  serious  conse- 
quences. Two  of  my  cases  illustrate  the  correctness  of  this  statement.  In 
one  of  these  cases  mortification  ensued,  and  the  patient  died  before  sloughing 
took  place.  The  other  case  came  under  observation  after  sloughing  of  the 
greater  part  of  the  scrotum  had  taken  place,  leaving  the  testicles  exposed. 
After  the  scarification  the  patient  was  tapped,  the  space  left  by  the  slough 
granulated  kindly,  and  when  I  last  saw  the  patient  the  part  had -nearly 
healed.  This  unexpected  cicatrization  seemed  to  me  to  furnish  a  striking 
illustration  of  the  general  improvement  resulting  from  the  removal  of  the 
dropsical  effusion  by  tapping. 

To  sum  up  in  a  few  words,  the  management  of  hydro-peritoneum,  so  far 
as  it  has  been  considered,  the  first  object  generally  being  to  effect  the 
removal  or  diminution  of  the  peritoneal  effusion,  we  may  make  cautious 
trial  of  diuretics  and  hydragogue  cathartics.  If  these  means  do  not  prove 
promptly  efficacious  (as  they  will  very  rarely  do),  it  is  useless  to  persist  in 
the  former  (diuretics),  and  injurious  to  continue  the  latter  (hydragogues). 
Tapping  should  be  resorted  to  so  soon  as  the  abdomen  becomes  distended, 
and  may  be  repeated  as  often  as  the  effusion  accumulates  sufficiently  to 
produce  distension.  If  the  system  be  not  much  debilitated,  all  alcoholic 
beverages  are  to  be  interdicted ;  and  if  these  seem  to  be  required,  or  the 
patient  have  not  sufficient  resolution  to  forego  their  use,  wine  and  malt 
liquors  should  be  substituted  for  spirit.  If  spirit  must  be  taken,  it  should 
be  taken  diluted  and  not  on  an  empty  stomach.  Tonic  remedies  are  to  be 
prescribed.  A  nutritious  diet  is  important,  and  the  quantity  of  liquid 
ingested  should  be  as  much  restricted  as  practicable,  the  object  being  to 
render  the  blood  rich  in  quality,  without  increase  of  quantity,  avoiding 
anaemia  and  hydraemia.  In  general  terms,  the  hygienic  conditions  should 
be  as  good  as  possible.  If  diarrhoea  exist,  it  may  be  relieved  by  appropriate 
remedies,  in  some  cases,  at  least,  without  injury,  if  not  with  benefit.  It  is 
dangerous  to  resort  to  scarifications  to  relieve  excessive  oedema  of  the  gen- 
ital organs. 

Course  and  termination  of  Hydro-peritoneum.  Prognosis. — Of 
the  46  cases  which  have  been  analyzed,  24,  as  already  stated,  either  ended 
fat.ally  under  my  observation,  or  the  patients  were  known  to  have  subse- 
quently died.  Of  the  22  non-fatal  cases,  in  8  there  had  been  no  improve- 
ment when  the  patients  were  last  seen  or  heard  from.    Doubtless  in  most, 


1863.]         Flint,  Clinical  Report  on  Hydro-Peritoneum.  337 

if  not  all  of  these  cases  the  termination  was  fatal.  In  4  cases,  when  the 
patients  were  last  seen,  or  heard  from,  more  or  less  improvement  had  taken 
place,  but  the  dropsical  affection  continued.  In  10  cases,  the  dropsy  having 
disappeared  or  been  removed  by  tapping,  the  patients  were  free  from  the 
affection  when  last  seen  or  heard  from.  The  period  during  which  it  is 
known  that  they  continued  exempt  from  dropsy,  varies  from  a  few  weeks 
to  eighteen  months.  In  only  two  of  the  cases  is  the  present  condition  of 
the  patients  known,  nor,  excepting  these  two  cases,  is  it  known  whether 
the  patients  are  living  or  dead.  In  one  of  the  two  cases  just  referred  to, 
the  patient  is  now  well  after  a  period  of  over  eighteen  months  from  her 
recovery,  and  in  the  other  case  the  patient  is  in  comfortable  health  eight 
months  after  recovery.  Exclusive  of  these  2  cases,  the  patients  were  in 
no  case  known  to  have  remained  free  from  dropsy  for  a  longer  period  than 
three  months,  and  in  most  of  the  cases  only  for  a  few  weeks.  They  were 
hospital  cases,  and  after  the  removal  of  the  dropsy,  with  more  or  less  gen- 
eral improvement,  they  were  discharged,  and  have  not  been  heard  from 
since  their  discharge.  It  is  by  no  means  fair  to  consider  these  8  cases  as 
having  terminated  in  recovery.  It  is  highly  probable  that  in  most  of  the 
cases  the  dropsy  subsequently  returned.  Of  the  two  excepted  cases,  in  one 
the  period  of  exemption  from  a  return  of  the  dropsy  (eight  months)  is 
hardly  long  enough  to  consider  the  recovery  as  permanent;  so  that,  in  fact, 
out  of  the  forty-six  cases  analyzed,  I  can  state  positively  that  recovery  has 
taken  place  in  but  a  single  instance.  This  is  the  case  of  Mrs.  W.,  which 
has  been  given  in  full. 

The  duration  of  the  disease,  dating  from  the  commencement  of  the 
dropsy,  in  the  fatal  cases,  varied  from  six  weeks  to  seventeen  months.  The 
average  duration  in  16  cases  is  about  five  months.  The  duration  of  the 
dropsy  in  the  cases  in  which  it  was  removed  and  did  not  return  while  the 
patients  were  under  observation,  varied  from  one  month  to  four  months. 

The  prognosis,  as  regards  permanent  recovery,  it  is  evident,  is  extremely 
unfavourable.  But  with  reference  to  this  point,  a  collection  of  cases  in 
which  patients  remained  under  observation  for  a  longer  period  after  appa- 
rent recovery,  is  desirable.  We  cannot  consider  a  patient  as  having 
recovered,  although  he  may  have  been  exempt  from  recurrence  of  effusion 
for  weeks  or  months,  if  pathological  conditions  remain  which  will  inevi- 
tably, sooner  or  later,  reproduce  the  dropsy.  The  facts  developed  by  this 
analysis,  however,  show  that  in  a  fair  proportion  of  cases  the  dropsy  may 
be  removed,  and  not  return  for  weeks  or  months,  the  patient,  in  the  mean- 
time, regaining  apparent  health.  We  are  warranted,  therefore,  under 
favourable  circumstances,  in  holding  out  encouragement  for  this  result  with 
the  possibility  of  permanent  recovery.1 

1  Since  this  article  was  written,  a  case  has  come  under  my  notice  of  much  inte- 
rest as  regards  apparent  recovery  after  tapping,  and  reproduction  of  the  dropsy  after 
the  lapse  of  several  years.    The  patient  was  admitted  into  Bellevue  Hospital  with 

No.  XC— April  1863.  22 


338 


Flint,  Clinical  Report  on  Hydro-Peritoneuiii.  [April 


The  most  favourable  circumstances  are  those  which  go  to  show  that  the 
dropsy  is  dependent  on  some  functional  condition,  and  not  on  hepatic 
lesion  ;  the  cases,  however,  in  which  we  are  warranted  in  coming  to  this 
conclusion,  are  exceedingly  infrequent.  But  assuming  the  existence  of 
structural  disease  of  the  liver,  circumstances  are  favourable  which  render  it 
probable  that  the  dropsy  depends,  not  exclusively  on  the  hepatic  disease, 
but,  to  a  greater  or  less  extent,  on  associated  morbid  conditions  which  we 
are  able  to  control,  such  as  ansemia,  general  debility,  diarrhoea,  intermittent 
fever.  In  other  words,  the  prognosis  is  unfavourable  in  proportion  as  we 
have  reason  to  believe  that  the  dropsy  is  exclusively  due  to  irremediable 
lesion  of  the  liver.  If  the  liver  have  undergone  structural  change,  perma- 
nent recovery  is  not  to  be  expected,  but  it  is  to  be  borne  in  mind  that 
dropsy  may  be  removed  and  not  return  for  an  indefinite  time,  notwithstand- 
ing a  certain  amount  of  immediate  hepatic  lesion.  When,  therefore,  there 
is  reason  to  believe  that  dropsy  involves  the  existence  of  cirrhosis  (which 
is  true  of  the  vast  majority  of  cases),  although  we  cannot  look  for  perma- 
nent recovery,  we  may  hope,  if  the  circumstances  of  the  case  are  not  other- 
wise unfavourable,  that,  after  the  removal  of  the  dropsy,  the  patient  may 
be  exempt  from  a  recurrence  of  the  affection  for  a  long  period,  and  that,  in 
the  mean  time,  with  judicious  management,  a  comfortable  state  of  health 
may  be  secured.  The  liver,  doubtless,  like  other  important  organs,  has  a 
functional  capacity  exceeding  greatly  the  necessities  of  the  economy.  Like 
the  lungs,  kidneys,  stomach,  heart,  etc.,  it  may  be  damaged  to  a  greater  or 
less  extent,  and  yet  be  competent  for  the  duty  required  of  it.  As  proof  of 
this,  in  fatal  cases  of  cirrhosis,  death  generally  takes  place  by  asthenia, 
induced  by  the  serous  transudation,  the  disturbance  of  the  functions  of  the 
thoracic  and  abdominal  organs  by  the  pressure  of  the  liquid,  the  difficulty 
attending  the  introduction  into  the  general  circulation  of  the  nutritious 
supplies  in  the  portal  blood,  etc.,  and  not  from  the  reabsorption  of  bile  or 
the  retention  in  the  blood  of  excrementitious  biliary  principles.  Assuming 
that  the  liver  has  received  a  certain  amount  of  damage  from  structural 
change,  there  are  two  great  ends  to  be  desired :  First,  that,  if  possible, 
further  damage  shall  not  occur ;  and,  Second,  that  the  powers  of  the  sys- 
tem may  be  preserved,  so  as  to  tolerate,  as  well  and  as  long  as  possible,  the 
structural  change  already  existing  and  which  must  continue. 

hydro-peritoneum  which  had  existed  for  two  months,  having  been  developed  after 
intermittent  fever.  Eight  years  ago  he  had  this  disease,  and  at  the  end  of  four 
months  was  tapped.  The  tapping  was  repeated  after  an  interval  of  two  weeks. 
There  was  no  return  of  the  dropsy  for  six  years,  and  during  that  time  he  had 
good  health.  Two- years  ago  the  dropsy  returned,  and  he  had  haematemesis.  Five 
weeks  from  the  commencement  of  the  dropsy  he  was  tapped.  The  dropsy  returned, 
but  disappeared  under  the  use  of  medicines,  and  he  remained  free  from  it  until 
two  months  ago.  He  has  continued  to  drink  spirits  more  or  less  prior  to,  and 
ever  since  the  first  occurrence  of  the  dropsy. 


1863.]         Johnston,  Antidote  for  Corrosive  Sublimate. 


339 


Circumstances  which  preclude  much  expectation  of  improvement,  are  : 
the  coexistence  of  cardiac  or  renal  disease  ;  considerable  emaciation  ;  suf- 
ficient debility  to  keep  the  patient  in  bed ;  jaundice ;  greatly  impaired 
appetite  and  digestion ;  speedy  reaccumulation  of  liquid  after  tapping. 
When  more  or  less  of  these  unfavourable  circumstances  are  present,  the 
physician  can  hardly  hope  to  do  more  than  to  retard  the  progress  toward 
a  fatal  termination. 

In  conclusion,  unpromising  as  are  the  majority  of  the  cases  of  hydro- 
peritoneum,  I  cannot  but  believe  that,  as  regards  prolongation  of  life  and 
as  much  improvement  of  health  as  is  compatible  with  existing  structural 
disease,  the  success  of  medical  practice  would  be  enhanced  by  employing 
less  than  has  been  the  custom  of  physicians,  diuretics,  hydragogue 
cathartics,  and  other  depressing  remedies,  by  resorting  earlier  than  is 
usually  done  to  tapping,  and  by  a  greater  reliance  on  tonic  medication, 

together  with  hygienic  measures  to  invigorate  and  strengthen  the  system. 

■ 


Art.  III. — On  Gold  Dust  and  Iron  Filings,  as  an  Antidote  for  Corrosive 
Sublimate.    By  Christopher  Johnston,  M.D.,  Baltimore,  Md. 

In  the  year  1841  a  rejected  lover,  at  that  time  a  visitor  in  Baltimore, 
committed  suicide  by  taking  a  large  dose  of  the  corrosive  chloride  of  mer- 
cury. The  case  fell  into  the  hands  of  Dr.  Thomas  H.  Buckler,  who  em- 
ployed, unavailingly,  all  the  known  antidotes  for  this  destructive  agent, 
and  had  the  misfortune  to  see  his  patient  die  in  great  agony.  The  failure 
of  art  to  relieve  made  a  strong  impression  upon  Dr.  Buckler,  and  he  forth- 
with instituted  experiments  with  the  view  of  ascertaining  by  observation 
the  efficacy  and  value  of  the  various  articles  used  or  proposed  to  counteract 
the  poisonous  effects  of  the  mercurial  salts. 

In  the  course  of  these  experiments  upon  pigs  and  dogs,  it  occurred  to 
him  to  magnify  the  galvanic  test  into  an  antidote — for,  said  he,  if  the  cor- 
rosive chloride  in  solution,  being  placed  on  a  bright  gold  surface,  and 
touched  with  an  iron  point  which  is  also  brought  in  contact  with  the  gold, 
undergoes  decomposition,  there  is  no  reason  why  gold  and  iron  in  the  form 
of  powder,  as  exposing  great  surface,  should  not  also  separate  chlorine  and 
mercury  in  combination  in  the  living  stomach.  Besides,  the  elements  are 
instantly  appropriated  by  the  antidotal  agents,  "the  mercury  attaching 
itself  to  the  negative  electrode,  namely,  the  gold,  while  the  chlorine  unites 
with  the  iron  of  the  positive  electrode  to  form  chloride  of  iron  ;  and  thus, 
for  a  highly  dynamic  substance,  we  substitute  a  comparatively  inert  amal- 
gam of  gold  and  a  harmless  chloride  of  iron." 

Accordingly  into  the  stomach  of  pigs  and  dogs  he  introduced  poisonous 


340  Johnston,  Antidote  for  Corrosive  Sublimate.  [April 

doses  of  the  corrosive  chloride  of  mercury,  taking  care  to  control  the  oeso- 
phagus :  and  then,  after  various  intervals,  he  passed  an  estimated  quantity 
of  gold  dust  and  iron  filings  into  the  stomach  of  a  portion  of  the  animals. 
All  the  poisoned  animals  which  had  not  received  the  antidote  became  the 
victims  of  the  experiment ;  and  of  the  others,  those  only  died  which  had 
presented  very  severe  symptoms  before  the  administration  of  the  remedy. 

These  results  were  published  by  Dr.  Buckler  in  the  Baltimore  Medical 
and  Surgical  Journal  in  1843,  with  a  recommendation,  by  the  author,  of 
the  new  antidote  which  he  proposed.  But  the  suggestion  seemed  to  have 
received  no  attention  whatever,  until,  in  the  last  year,  a  case  of  corrosive 
sublimate  poisoning  occurred  to  us,  in  the  which  we  essayed  for  the  first 
time  gold  dust  and  iron  filings  upon  the  human  subject. 

We  had  had  the  good  fortune  to  witness  a  repetition  of  Dr.  Buckler's 
experiments,  and  were  familiar  with  his  views  in  respect  of  the  agency  at 
work  ;  so  that  we  only  awaited  a  fitting  opportunity  for  testing  the  value 
of  our  friend's  proposition. 

On  the  14tja  of  May  last,  a  gentleman  of  this  city,  being  disturbed  in 
mind,  procured  two  drachms  (5ij)  of  corrosive  sublimate  from  an  apothe- 
cary, assigning  as  a  reason  his  intention  of  destroying  rats  ;  mixed  two- 
thirds  of  the  salt  with  whiskey  and  water  and  swallowed  the  whole  at  a 
draught,  leaving  no  dregs  in  the  tumbler.  In  about  ten  minutes  his  wife, 
hearing  efforts  at  vomiting  in  her  chamber,  proceeded  thither,  and  found 
her  husband  sitting  up  in  violent  and  agonizing  emesis.  A  word  and  the 
fatal  paper  satisfied  her  as  to  the  danger  of  the  sufferer ;  whereupon  she 
dispatched  a  messenger  for  medical  aid,  but  administered  the  while  milk 
and  white  of  egg,  having  in  a  previous  marriage  been  the  observant  wife  of 
a  physician. 

In  five  minutes — it  so  happened — we  were  at  the  bedside,  and  the  gal- 
vanic antidote  being  present  in  our  mind,  we  sent  in  haste  for  two  drachms 
of  iron  by  hydrogen,  and  a  book  of  gold-leaf.  While  waiting  for  the 
arrival  of  the  articles  we  encouraged  perseverance  in  the  use  of  albumen 
and  milk,  but  the  patient  continued  to  vomit  freely,  violently,  and  uninter- 
mittingly.  Everything  swallowed  was  rejected  as  soon  as  it  approached 
the  stomach,  and  then,  after  sturdy  efforts,  small  quantities  of  greenish 
mucus,  streaked  with  blood,  were  discharged.  The  face  was  much  con- 
gested, the  body  cold,  and  the  whole  surface  bedewed  with  sweat. 

In  less  than  ten  minutes  (in  all  somewhat  short  of  twenty-five  minutes 
from  the  ingestion  of  the  sublimate)  we  had  prepared  a  bolus  by  dusting 
the  surface  of  a  leaf  of  gold  with  the  iron,  over  this  another  leaf,  then 
iron,  and  so  on,  alternating  the  two  metals  until  about  one-half  of  the  gold 
leaf  had  been  expended,  and  the  mass  was  rolled  into  a  ball. 

Before  swallowing  this,  however,  we  administered  warm  water  to  effect 
the  removal  of  mucus,  albumen,  and  milk,  should  any  of  these  matters  be 
in  the  stomach,  as  they  must  defend  the  sublimate  from  the  action  of  the 
antidote  by  preventing  contact.    Instant  emesis  followed. 


1863.] 


Johnston,  Antidote  for  Corrosive  Sublimate. 


341 


The  bolus  was"  readily  taken  into  the  stomach,  aided  by  a  little  water, 
for  the  poisoned  man  regretted  his  act  and  wished  to  escape  from  death. 
For  five  minutes  there  was  a  calm,  during  which  we  made  another  bolus 
with  the  remainder  of  the  gold-leaf  and  iron. 

Vomiting  now  recurred,  but  with  less  violence,  and  the  matters  ejected 
were  tinged  with  yellow  or  light  brown,  and  contained  particles  of  gold-leaf. 

Presently  another  moment  of  quiet  occurred,  which  was  the  signal  for 
the  administration  of  the  second  bolus.  Yomiting  now  ceased  entirely, 
although  at  intervals  for  an  hour  a  slight  tendency  towards  emesis  was 
observable — but  the  frantic,  tremulous  anxiety,  had  given  place  to  confi- 
dence and  composure — the  man  had  assumed  a  hopeful  appearance,  and  we 
were  of  opinion  that  the  first — the  greatest  danger — was  past. 

On  the  next  day  moderately  severe  ptyalism  manifested  itself;  but  the 
convalescence  was  rapid,  and  the  cure  was  complete  in  about  eight  days. 

The  after-treatment,  when  vomiting  was  arrested,  was  very  simple,  con- 
sisting of  hydrocyanic  acid  in  mucilage  with  small  doses  of  morphia  ;  mu- 
cilaginous drinks,  as  of  gum  Arabic,  or  quince  seed,  were  directed  ;  and  beef- 
tea  and  arrowroot  were  the  essential  articles  of  diet  for  some  days.  Ro- 
chelle  salt  dissolved  in  soda  water  was  given  on  the  first  days,  and  counter- 
irritation  over  the  epigastrium  practised  from  the  beginning,  and  continued 
until  all  signs  of  gastric  disturbance  had  disappeared.  And,  to  conclude 
the  statement,  the  mouth  symptoms  were  met  by  gargles  of  tinct.  perchlo- 
ride  of  iron  largely  diluted  with  water,  alum  in  infusion  of  sage,  and  lastly, 
flaxseed  tea  acidulated  with  lemon. 

We  would  not  insist  upon  the  superior  efficacy  of  gold-leaf  and  of  iron 
by  hydrogen  over  gold  dust  and  fresh  iron  filings — although  in  the  case 
reported  the  virtue  of  the  former  was  apparent  to  and  acknowledged  by 
all  the  witnesses — for  we  have  still  a  preference  for  the  latter,  on  account 
of  the  freshness  of  the  metallic  surfaces.  But  in  the  hurry  of  the  moment 
the  first  mentioned  may  be  easily  obtained  in  a  state  of  preparation  except- 
ing on  Sundays,  and  then  even  a  dentist  would  furnish  gold-foil  No.  4  or 
lighter,  which  would  supply  the  place  of  gold-leaf.  If  the  conveniences 
were  at  hand,  or,  if  we  were  near  a  pharmaceutist's,  we  would  prefer  to 
grind  gold-foil  with  fresh  iron  filings  in  a  mortar,  and  exhibit  the  coarse 
powder  so  produced  with  a  little  water  ;  for  the  heavier  particles  would 
more  quickly  find  their  way  to  the  mucous  coating  of  the  depending  por- 
tion, while  enough  of  the  finer  particles  would  distribute  themselves  through- 
out the  stomach  to  accomplish  the  destruction  of  the  corrosive  chloride  not 
in  contact  with  the  mucous  membrane. 

With  regard  to  the  quantity  and  proportions  of  gold  and  iron  to  be 
administered  together  as  an  antidote  for  the  corrosive  mercurial  salt,  it  is 
desirable  to  know  approximately  the  amount  of  the  poison  taken  ;  but  this 
is  not  indispensable,  for  an  overdose  of  the  remedy  would  occasion  no 
"  unpleasant"  consequences.    Lest  an  insufficient  quantity  of  the  metals  be 


342 


Ashhurst,  Surgical  Cases. 


[April 


exhibited,  a  reference  to  the  table  of  equivalents  is  necessary.  As  for  mer- 
cury and  gold  there  is  much  discrepancy  among  authors,  but  if  we  adopt 
for  Hg  100.1  (Erdmann)  for  Au  196.44  (Berzelius),  for  Fe  28.04  (Erd- 
mann)  and  for  CI  35.5  (Berzelius),  we  have  for  corrosive  sublimate  the 
formula  HgCl  (100.1-f-35.5)  =  135.6,  and  100  grains  would  contain  Hg 
73.82,  and  CI  26.18.  Now,  since  the  corrosive  sublimate  in  the  presence 
of  gold  and  iron  is  reduced,  and  there  are  formed  an  amalgam  of  gold  and 
sesquichloride  of  iron,  we  must  know  how  much  iron  is  needed  to  make 
that  compound  with  CI  26.18.  The  formula  for  the  sesquichloride  is 
Fe2Cl3  (56.08+106.5)=162.58;  therefore  in  39.96  grains  we  have  CI 
26.18  combining  with  Fe  13.78,  the  quantity  sought. 

Again,  to  estimate  the  gold,  assuming  the  amalgam  formed  to  be  in 
equivalent  proportions,  we  find  AuHg  (196.44-f-100.1)=296.54 ;  and  in 
218  grains  we  discover  144.86  grains  of  the  precious  metal,  and  73.82 
grains  of  mercury.  Or,  if  we  employ  the  equivalents  adopted  by  Cahours, 
thus,  Au  98.18  (not  far  from  Graham,  Au  99.6)  and  Hg  103),  we  have 
140.92  grains  of  amalgam  yielding  67.10  grains  of  gold.  In  short,  we 
need  144.86  grains  of  gold  (or  else  67.10  grains)  to  appropriate  the  mer- 
cury liberated  by  the  action  of  the  reagents.  This  discrepancy  is  not  likely 
to  lead  to  ill-results,  for,  if  we  use  the  larger  number,  we  might  be  quite  at 
ease  about  the  amalgam  produced,  and  it  is  not  certain  that  the  lesser  quan- 
tity would  contribute  to  form  an  amalgam  more  nocuous  than  the  other. 

To  sum  up  :  For  100  grains  of  the  corrosive  sublimate  of  mercury  taken 
there  would  be  required  of  iron  13.78  grains,  or  rather  less  than  the  ^th 
part  by  weight,  and  of  gold  dust  144.86  grains,  or  about  one  and  a  half 
times  the  weight,  to  effect  the  decomposition  of  the  poison  and  the  com- 
plete appropriation  of  its  elements.  If  we  follow  Cahours  we  need  only 
employ  67.10  grains  of  gold. 

In  conclusion  we  would  remark,  that  very  large  doses  of  the  antidote 
must  be  rarely  needed,  since  vomiting,  which  marks  the  earliest  effects  of 
the  corrosive  chloride  of  mercury,  necessarily  rids  the  stomach  of  some 
portion  of  the  destructive  agent. 

January  19,  1863. 


Art.  IV. — Surgical  Cases,  Illustrating  some  Practical  Points.  By 
John  Ashhurst,  Jr.,  M.D.,  of  Philadelphia. 

The  following  cases  are  selected,  not  from  any  peculiar  intrinsic  interest, 
nor  from  a  supposition  that  they  are  in  any  degree  rare  or  unusual-;  but 
because  it  is  believed  they  will  serve  to  illustrate  one  or  two  points  in  prac- 
tice about  which  much  diversity  of  opinion  exists,  and  which  the  present 
war  ought  to  settle,  if  not  definitively,  at  least  more  certainly  than  has 
hitherto  been  done. 


1863.] 


Ashhurst,  Surgical  Cases. 


343 


These  cases  were  all  advanced  into  the  secondary  stage,  or  that  of  sup- 
puration, when  first  brought  to  the  Chester  hospital,  where  I  observed 
them.  Had  the  necessity  for  operative  interference  been  more  quickly  re- 
cognized, there  is  no  doubt  the  results  would  have  been  more  favourable. 
The  statistics  of  secondary  amputation  in  gunshot  wounds  are  so  unsatis- 
factory, that  the  operation  was  only  employed  when  it  seemed  any  other 
course  would  insure  death.  And  this,  I  think,  should  be  the  rule ;  in  the 
case  of  primary  operations,  the  sooner  the  better.  "Every  hour,"  says 
McLeod,  "the  humane  operation  is  delayed,  diminishes  the  chances  of  a 
favourable  issue."  (Notes  on  Surgery  of  Crimean  War,  Am.  ed.,  p.  319.) 
But  when  the  golden  opportunity  has  been  lost ;  when,  for  any  reason,  the 
attempt  to  save  a  limb  has  been  made,  and  the  suppurative  stage  has  fairly 
come  on,  amputation  should  not  be  resorted  to,  unless  the  patient's  general 
health  begins  to  give  way,  when  of  course  the  limb  must  be  sacrificed  in 
the  endeavour  to  preserve  life. 

It  is  the  popular  opinion,  unfortunately  encouraged  by  some  of  the  profes- 
sion, in  this,  as  it  has  been  in  every  other  war,  that  army  surgeons  are  too 
prone  to  operate,  and  that  limbs  are  daily  sacrificed  that  might  be  saved ; 
but  the  same  conviction  is  gradually  coming  to  us  that  was  forced  on 
McLeod,  on  Hennen,  on  Dupuytren,  on  Baudens,  on  Begin,  on  Larrey, 
and  Guthrie ;  that,  in  trying  to  save  limbs,  we  lose  lives.  "  At  the  outset 
of  my  career,"  said  Begin,  "I  amputated  less  than  I  did  toward  the  end  of 
my  service,"  and  the  same  is  the  experience  of  all.  I  suppose  there  is 
hardly  a  surgeon  in  the  Federal  army  who  does  not  know  of  one  or  more 
lives  sacrificed  to  "conservative  surgery,"  so  called. 

I  shall  narrate  the  cases  I  have  to  report  in  the  order  in  which  they 
occurred,  and  shall  afterwards  call  attention  to  one  or  two  points  of  interest 
connected  with  them. 

Case  1.  Private  Faulkner,  Co.  H.,  70th  N.  Y.  Yols.,  was  wounded  in  one 
of  the  battles  before  Richmond  in  the  latter  part  of  August,  1862.  A  flesh 
wound  of  the  abdominal  parietes  in  front,  and  a  comminuted  fracture  of 
both  bones  of  the  left  forearm  just  above  the  wrist,  were  the  effects  of  the 
same  ball.  He  came  to  the  army  hospital  at  Chester,  Pa.,  on  September 
3d,  and  was  placed  in  the  ward  of  which  at  that  time  I  had  charge. 

As  suppuration  was  already  established,  and  the  case  seemed  to  be  pro- 
gressing favourably,  the  arm  was  lightly  dressed,  and  kept  at  rest  on  an 
appropriate  splint.  About  the  middle  of  September,  however,  the  limb 
became  much  inflamed,  and  it  was  rendered  evident  that  the  destruction  of 
bone  was  much  greater  than  had  been  supposed ;  and  that,  in  all  proba- 
bility, the  wrist-joint  itself  was  involved.  At  the  same  time  the  wounds  of 
the  abdominal  region  assumed  an  unhealthy  appearance,  diarrhoea  set  in, 
and  the  patient  became  daily  more  prostrated. 

Free  incisions,  soothing  applications,  and  all  means  that  a  desire  to  save 


344 


Ashhurst,  Surgical  Cases. 


[April 


the  limb  could  suggest  were  employed,  but  without  avail ;  and  on  the  25th 
September  it  was  decided,  in  consultation,  that  the  forearm  must  be  re- 
moved. 

I  accordingly  performed  the  operation  the  same  afternoon,  the  patient 
being  under  the  influence  of  ether,  by  the  method  of  Mr.  Teale.  Sixteen 
ligatures  were  applied,  the  flaps  brought  together  by  points  of  lead  suture, 
and  the  stump  kept  wet  with  an  anodyne  wash.  Light,  but  nutritious 
diet,  six  fluidrachms  of  brandy  every  hour,  with  tonics  and  anodynes  cau- 
tiously administered,  constituted  his  treatment.  The  patient  rapidly  im- 
proved, the  flaps  adhered  throughout,  except  where  the  ligatures  escaped, 
and  recovery  followed  without  a  single  unfavourable  symptom.  When  I 
last  saw  this  man,  in  December,  he  was  awaiting  his  discharge,  not  having 
been  under  any  treatment  for  a  long  while,  and  his  stump  as  full  and 
plump  almost  as  on  the  day  of  operation. 

Case  2.  Corporal  Warren,  Co.  H.,  20th  Mass.  Vols.,  at  the  battle  of 
Antietam,  September  17th,  received  a  gunshot  fracture  of  the  right  humerus, 
and  entered  the  Chester  hospital  on  the  2d  October  following.  The  next 
day  a  portion  of  ball  was  removed  by  a  counter-opening  on  the  outside  of 
the  arm,  the  track  of  the  original  wound  being  antero-posterior,  and  in  the 
middle  third.  Subsequently  the  wound  of  entrance  was  enlarged/  and  a 
fragment  of  bone,  which  was  loose,  extracted.  By  the  finger,  which  could 
be  easily  introduced  into  the  posterior  wound,  that  of  exit,  it  was  found 
that  a  large  fragment  of  the  lower  part  of  the  humerus  was  dead  and  par- 
tially loose.  It  was  therefore  determined,  in  consultation,  to  enlarge  this 
wound,  remove  all  loose  pieces  of  bone,  and,  if  necessary,  saw  off  the  pro- 
jecting extremities  of  either  portion. 

Accordingly,  on  the  afternoon  of  the  11th,  the  patient  was  brought 
under  the  influence  of  ether,  and  a  free  incision  made  longitudinally  down- 
wards from  the  wound  of  exit.  It  was  found,  by  the  examination  which 
could  now  be  made,  that  the  destruction  of  bone  was  much  greater  than 
had  been  at  all  imagined,  and  resection  was  resolved  upon,  which  it  was 
supposed  would  give  a  reasonable  prospect  of  preserving  the  limb. 

Access  to  the  bone  was  facilitated  by  a  transverse  incision,  starting  also 
from  the  wound  of  exit,  the  upper  end  of  the  lower  fragment  removed  by 
means  of  a  metacarpal  saw,  and  the  projecting  part  of  the  lower  fragment 
by  bone-nippers.  Only  a  few  small  vessels  required  ligature,  the  wound 
was  accurately  closed,  and  the  limb  placed  at  rest  on  a  splint.  With  the 
exception  of  a  very  profuse  suppuration  and  consequent  failing  strength  of 
the  patient,  everything  progressed  favourably  until  early  in  the  morning 
of  the  18th,  one  week  after  the  operation,  when  a  profuse  secondary  hemor- 
rhage took  place,  stopping  of  itself  by  the  time  I  reached  the  ward. 

It  was  now  decided,  should  hemorrhage  recur  to  any  considerable  amount, 
as  the  patient  was  already  much  weakened  by  suppuration  and  the  subse- 
quent loss  of  blood,  to  perform  amputation  above  the  seat  of  injury. 


1863.] 


Ashhurst,  Surgical  Cases. 


345 


Another  hemorrhage,  of  a  still  more  alarming  extent,  did  take  place  the 
next  afternoon,  and,  accordingly,  the  patient  being  under  the  influence  of 
ether,  T  removed  the  arm  in  its  upper  third,  oval  skin -flaps  being  obtained 
from  the  front  and  back  of  the  arm,  and  the  muscles  divided  by  a  circular 
incision  higher  up.  Yery  little  blood  was  lost,  thirteen  ligatures  being 
employed,  and  the  flaps  brought  together  by  the  lead  suture.  For  several 
days  the  patient  hung  between  life  and  death,  but  nature  finally  triumphed, 
and  recovery,  after  amputation,  was  even  more  rapid  than  had  been  the 
sinking  after  the  "conservative"  operation  of  resection. 

Case  3.  Corporal  Burnham,  Co.  D.,  132d  Pa.  Vols.,  admitted  also  on 
October  2d,  with  a  gunshot  fracture  of  the  left  radius,  received  at  the  battle 
of  Antietam.  For  some  weeks  the  case  was  treated  by  the  ordinary 
methods,  but  at  the  end  of  that  time  it  was  found  that  the  radius  had 
become  necrosed  for  a  space  of  about  three  inches,  and  apparently  in  its 
entire  thickness.  Resection  was  at  first  proposed,  but,  in  view  of  the  man's 
broken  down  condition,  the  risk  of  secondary  hemorrhage  or  sloughing, 
and  consequent  necessity  for  a  subsequent  operation,  and  the  patient's  own 
expressed  preference  for  amputation,  the  latter  course  was  adopted,  and  I 
removed  the  forearm  a  short  distance  below  the  elbow  on  October  28th,  by 
making  two  oval  flaps,  antero-posterior,  cut  from  without  inwards,  the 
patient  being  under  the  influence  of  ether.  Consecutive  hemorrhage  re- 
quired the  stump  to  be  opened  the  same  evening,  and  finally  could  only  be 
stopped  by  plugging  either  bone  with  a  pellet  of  wax,  and  inserting  several 
thicknesses  of  patent  lint  between  the  flaps,  which  were  then  held  together 
by  strips  of  adhesive  plaster. 

Oct.  30,  j^oth  flaps  presented  healthy  granulations,  the  lint  was  removed, 
and  the  flaps  kept  in  position  as  before. 

Nov.  2  (five  days  after  the  operation),  a  secondary  hemorrhage.  On 
opening  the  stump  the  bleeding  vessel  was  found  and  tied. 

Nov.  ith,  4  A.  M.,  another  hemorrhage,  stopping  of  itself,  and  followed  by 
still  another  about  three  hours  later.  It  was  now  determined  to  ligate  the 
brachial  artery,  which  was  accordingly  done,  the  patient  reacting  with  dif- 
ficulty from  the  anaesthesia  which  had  been  again  produced,  and  being 
exceedingly  feeble  from  the  repeated  loss  of  blood.  The  brachial  artery 
was  found  to  have  divided  high  up,  and  both  branches  were  accordingly 
secured.  For  some  days  he  seemed  to  improve,  then  sloughing  and  nume- 
rous abscesses  around  the  joint  followed,  hemorrhage  recurred  from  both 
wounds,  and  death  closed  the  scene  on  November  15,  eleven  days  after  the 
ligation  of  the  brachial  artery,  and  eighteen  after  the  amputation.  No 
post-mortem  examination  was  obtained. 

Case  4.  Private  Donnell,  Co.  B.,  27  th  N.  C.  Hegt.  (rebel  prisoner), 
also  wounded  at  the  battle  of  Antietam,  and  admitted  on  October  2d. 
The  wound,  which  appeared  to  be  simply  a  flesh  wound,  did  well,  and 


346 


Ashhurst,  Surgical  Cases. 


[April 


was  nearly  healed,  when,  from  some  then  unknown  cause,  the  track  re- 
opened, and  by  the  probe  and  little  finger  dead  bone  was  detected  about 
the  middle  of  the  left  femur.  After  some  time  rigors  and  hectic  supervened, 
and  it  became  evident  that,  unless  an  operation  could  alter  the  state  of 
things,  death  must  inevitably  occur,  and  that  in  a  very  short  time.  Am- 
putation was  accordingly  determined  on,  and  the  patient  being  etherized,  I 
removed  the  thigh  about  the  junction  of  the  upper  and  middle  thirds  by 
the  circular  incision  on  the  afternoon  of  November  6.  The  patient  with 
great  difficulty  reacted  from  the  state  of  anaesthesia,  but  subsequently  sank 
suddenly,  and  died  seven  hours  after  the  operation.  The  femur  was  found 
necrosed  in  its  entire  thickness,  and  a  large  mass  of  soft  callus  had  been 
thrown  out,  between  which  and  the  dead  shaft  a  foyer  of  pus  existed. 

The  points  to  which  I  wish  to  refer  in  these  cases,  and  which  I  consider  of 
great  practical  importance  are  :  L  Resection  in  the  continuity  of  long  bones 
as  a  substitute  for  amputation,  and  as  an  aid  to  nature  in  compound  fractures. 
2.  Ligation  of  main  arteries  as  a  remedy  for  secondary  hemorrhage.  3. 
The  importance  of  amputating  soon  when  the  operation  is  to  be  done 
at  all. 

The  excision  of  the  articular  extremities  of  the  long  bones  for  injuries 
of  the  joints  is  an  operation  now  firmly  and  justly  established  as  truly  con- 
servative. The  removal  of  portions  of  the  shaft  of  long  bones  for  necrosis 
has  been  done  with  occasional  good  results.  "Such  operations,  however," 
says  Holmes,  "whether  undertaken  on  account  of  caries  or  necrosis,  too 
often  result  in  failure."  (Syst.  of  Surgery,  vol.  iii.  p.  830.) 

The  same  author,  in  his  edition  of  Wagner's  treatise  on  the  process  of 
repair  after  resection  and  excision  of  bone,  has  collected  seven  cases  of 
resection  from  the  substance  of  bone,  only  three  of  which,  ht>wever,  are 
apposite  to  the  present  discussion.  In  one  of  these,  the  ulna  being  the 
bone  concerned,  "the  movements  of  the  arm  including  rotation,  were  almost 
perfectly  restored."  In  another,  where  a  great  part  of  the  tibia  was 
removed,  after  three-quarters  of  a  year,  "in  spite  of  the  uninjured  fibula, 
shortening  of  more  than  two  inches  had  occurred."  While  in  the  third, 
also  a  resection  of  the  tibia,  "the  limb  remained  useless,  and  the  leg  was 
amputated  eight  months  afterwards."  (Selected  Monographs.  New.  Syd. 
Soc,  pp.  239-240.) 

These  were  resections  under  favourable  circumstances,  for  in  operations 
for  disease,  the  periosteum  can  generally  by  preserved,  thus  giving  a  chance 
for  the  formation  of  new  bone. 

A  great  deal  is  said  at  the  present  time  about  subperiosteal  resection. 
"  Some  writers,"  says  Mr.  Holmes,  "  speak  about  subperiosteal  resections 
of  joints,  in  such  terms  that  one  is  almost  disposed  to  think  that  they 
imagine  the  possibility  of  dissecting  out  the  end  of  the  shaft  of  a  large 
bone,  like  the  femur  or  the  humerus,  and  leaving  behind  a  sleeve  of  perios- 
teum, which  is  to  reproduce  the  bone.    Such  an  idea  is  preposterous. 


1863.] 


Ashhtjrst,  Surgical  Cases. 


347 


The  attempt  would  only  result  in  leaving  some  irregular  shreds.  M. 
Ollier's  experiments  show  that  such  shreds  will,  in  the  lower  animals,  pro- 
duce irregular  nodules  of  bone.  Probably  this  would  not  be  so  in  man  ; 
but  if  it  were,  such  nodules  would  be  more  often  in  the  way  than  other- 
wise.'1   (Syst.  of  Surgery,  vol.  iii.  p.  803.) 

Oilier  has  indeed  gone  further  than  this,  and  has  shown  that  in  animals, 
an  entire  articulation  may  be  reproduced ;  and  even  suggests  a  new  opera- 
tion, *'  osteoplastie  periostique,"  as  being  quite  possible.  Although,  how- 
ever, nearly  four  years  have  elapsed  since  the  publication  of  his  paper 
{Journal  de  la  Physiologie  de  V Homme  et  des  Animaux,  Avril,  1859), 
I  am  not  aware  that  even  an  attempt  has  been  made  to  carry  out  his  pro- 
posal. 

But  whatever  may  be  the  results  and  prospects  of  resection  in  cases  of 
necrosis,  gunshot  or  other  injuries  present  a  different  position  of  affairs ; 
here  the  preservation  of  the  periosteum  may  be  looked  upon  as  practically 
an  impossibility,  and  the  best  result  that  can  be  hoped  for  is  a  shortened 
and  twisted  limb.  If  the  end  of  a  broken  bone  project  through  the  skin, 
and  the  fracture  can  in  no  other  way  be  reduced,  it  would  seem  reasonable 
to  saw  off  the  projecting  portion,  and  thus  remove  the  obstacle  to  the 
proper  adjustment  of  the  fragments.  But  if  this  particular  contingency 
be  not  present,  and  deep  and  long  incisions  be  required  to  expose  the  in- 
jured bone,  the  question  is  different.  If  the  destruction  be  so  great  as  to 
render  an  operation  of  any  kind  necessary,  I  doubt  if  true  conservatism 
would  not  point  to  amputation;  because  for  one  limb  deformed  and  help- 
less perhaps,  which  resection  might  save,  I  fear  that  more  than  one  life 
would  be  sacrificed. 

Hence,  should  another  case  like  that  of  Corporal  Warren  occur  to  me, 
I  should  avoid  all  operative  interference  as  long  as  possible,  and  if  it  be- 
came finally  indispensable  to  do  anything  more  than  the  mere  removal  of 
sequestra,  I  should  advise  amputation  at  or  above  the  seat  of  injury. 

The  utmost,  I  conceive,  that  resection  in  such  a  case  could  accomplish, 
would  be  the  preservation  of  a  limb  of  doubtful  utility.  "I  cannot,"  says 
Mr.  Holmes,  "discover  any  evidence  of  the  restoration  of  the  continuity 
of  a  long  bone  after  its  interruption  by  the  resection  of  a  piece  of  its  shaft, 
except  in  cases  of  necrosis.  Probably  if  the  piece  were  very  short,  union 
might  occur ;  but  the  necessity  for  the  removal  of  such  a  piece  could  hardly 
ever  arise."  {Syst  of  Surgery,  vol.  iii.  p.  830.)  To  all  the  risks  of  a 
compound  fracture,  the  risks  of  a  capital  operation  are  added;  and  if  the 
necessity  for  subsequent  amputation,  as  in  my  case,  arises,  it  is  not  always 
that  the  patient  is  so  fortunate  as  to  survive  his  complicated  dangers. 

Xo  accident  following  operations  is  more  harassing  to  the  patient  and 
more  feared  by  the  surgeon  than  secondary  hemorrhage,  and  it  might  seem 
strange  that  the  profession  have  not  yet  arrived  at  any  unanimous  conclu- 
sion as  to  the  best  means  of  remedying  so  dreadful  an  occurrence.  Most 


348  Ashhurst,  Surgical  Cases.  [April 

surgeons,  if  not  of  the  present  day,  at  least  quite  recently,  have  supposed 
that  ligation  of  the  main  artery  above  the  seat  of  hemorrhage  was  the 
safest  and  surest  way  of  checking  bleeding.  But  the  fact  brought  so  pro- 
minently forward  by  Guthrie,  that  secondary  hemorrhage  in  almost  all 
cases  is  from  the  lower  or  distal  end  of  the  wounded  vessel,  explains  the 
frequent  failure  of  this  operation.  Undoubtedly  when  it  is  possible  to  do 
so,  Guthrie's  recommendation  should  be  carried  out ;  viz :  to  cut  down  at 
the  seat  of  hemorrhage  and  secure  both  ends  of  the  bleeding  vessel.  But 
in  many  cases  this  is  impossible.  By  the  time  the  bandages  and  dressings 
are  removed  the  hemorrhage  has  ceased,  and  the  bed  soaked  in  blood,  and 
the  patient's  fluttering  pulse  are  all  that  remain  to  tell  of  the  occurrence.  In 
such  a  case  forced  flexion  of  the  limb,  or  pressure  upon  the  main  vessels, 
will  sometimes  prevent  a  return  of  the  bleeding;  but,  as  a  general  thing, 
ligation  of  the  artery  above,  or  amputation,  are  the  only  means  that  pro- 
mise success ;  for  the  most  careful  scrutiny  may  fail  to  discover  any  patulous 
arterial  mouth. 

Ligation  is  of  course  looked  upon  with  favour,  as  giving  a  chance  of 
saving  the  limb. 

I  can  recall  very  weir  a  case  in  the  Pennsylvania  Hospital,  where,  for 
hemorrhage,  the  radial,  then  the  ulnar,  and  finally  the  brachial  artery  was 
tied  ;  and  the  man's  life  and  limb  were  both  saved.  But  I  fear  such  cases 
are  exceptional.  The  use  of  the  actual  cautery,  introduced  into  the  bleed- 
ing artery  through  a  canula,  as  practised  by  Mr.  Cline  (Souttts  Chelius, 
Am.  ed.,  vol.  i.  pp.  347-352)  would,  I  should  suppose,  be  very  efficient, 
but  for  the  fact  that  in  most  cases  of  secondary  hemorrhage  it  is  impossible 
to  find  the  bleeding  vessel. 

In  compound  fractures,  whether  from  gunshot  wounds  or  other  causes, 
ligation  of  the  principal  artery  will  not  only  generally  not  succeed  in  per- 
manently arresting  hemorrhage,  but  superadds  a  considerable  risk  of  gan- 
grene; while  even  in  bleeding  from  stumps,  where  it  would  seem  to  promise 
more  favourable  results  than  under  any  other  circumstances,  it  too  often 
proves  unavailing,  and  subsequent  amputation  or  death  obliges  the  unwil- 
ling surgeon  to  record  it  among  his  unsuccessful  operations. 

A  case,  narrated  by  Bertherand,  seems  so  appropriate  in  this  place  as  to 
merit  more  than  a  passing  reference : —  • 

"Captain  0  ,  who  had  been  wounded  in  the  upper  third  of  the  fore- 
arm by  a  ball  which  passed  between  the  two  bones,  after  a  considerable 
time  had  a  hemorrhage  which  was  attributed  to  a  wound  of  the  interosseous 
artery.  After  vain  efforts  to  control  it  by  the  application  of  Signoroni's 
compressor,  the  usual  haemostatics,  compression  direct  or  remote,  the  bra- 
chial artery  had  to  be  tied.  In  spite  of  this  remedy,  which  one  might  sup- 
pose would  be  final,  the  hemorrhage  soon  returned.  I  was  asked  to  see 
the  patient.  He  was  lodged  with  an  excellent  confrere,  who,  with  his  wife 
and  two  daughters,  maintained  from  hour  to  hour  a  digital  compression  on 
the  wounded  limb.   Having  assured  myself  of  the  reality  of  the  ligature  of 


1863.]  Ash  hurst,  Surgical  Cases.  349 

the  principal  trunk,  I  probed  the  wound  and  took  away  with  my  forceps  a 
fragment  of  lead.  I  then  passed  into  the  track  a  mesh  saturated  with  a 
solution  of  the  perchloride  of  iron,  and  the  bleeding  was  arrested.  As  the 
lower  end  of  the  vessel  might  be  the  source  of  the  accidents,  I  advised  the 
application  of  a  gauntlet  bandage  and  graduated  compresses,  methodically 
bound,  as  well  on  the  face  of  the  limb  as  in  the  interosseous  space,  and 
continued  as  high  as  the  wound,  an  elevated  position  for  the  hand,  perfect 
rest,  and  digital  compression  in  the  axilla.  In  spite  of  these  precautions 
the  dressings  were  again  the  next  day  tinged  with  red,  and  the  patient 
sinking,  all  resources  having  been  exhausted,  we  had  to  be  resigned  to  the 
cruel  necessity  of  amputation. 

"  I  have  since  learned  that  Captain  0  was  not  able  to  support  its 

consequences."  (Bertherand,  Campagne  d'ltalie,  pp.  159,  160.)  , 

,Who  can  say  that  here  the  "  humane  operation"  in  the  first  place  would 
not  have  been  truly  conservative.  I  am  aware  that  the  doctrine  I  am  advo- 
cating is  in  opposition  to  the  views  of  many,  probably  a  large  majority,  of 
the  most  eminent  names  in  surgery;  but  I  am  well  convinced  that  had  I  in 
Corporal  Warren's  case  tied  the  brachial  or  axillary,  instead  of  amputating, 
he  would  not  now  be  alive ;  while,  on  the  other  hand,  if  in  Burnham's  case 
I  had  amputated  above  the  elbow,  instead  of  tying  the  brachial,  it  is  not 
impossible  that  the  result  might  have  been  different. 

The  third  point  to  which  I  wish  to  direct  attention  is  the  importance, 
when  an  amputation  is  certainly  to  be  done,  of  doing  it  as  soon  as  possible. 
Many  a  life  has  been  sacrificed  to  the  hope  of  getting  the  patient  in  a  better 
condition  before  operating.  It  should  be  remembered  that  the  shock  of  an 
operation,  particularly  with  the  use  of  ether  and  opium,  is  a  very  slight 
matter;  while  the  presence  of  the  limb  to  be  sacrificed  is  a  positive  and 
constant  depressing  agency. 

Had  Faulkner's  arm  been  left  on  a  few  days  longer,  in  the  hope  of  his 
being  better  able  to  support  the  operation,  I  believe  the  operation  would 
have  come  too  late.  Had  Donnell's  thigh  been  sacrificed  at  the  first  mani- 
festation of  unfavourable  symptoms,  his  life  might  possibly  have  been  pre- 
served. 

On  the  other  hand,  no  secondary  amputation  should  be  performed  for 
mere  probable  cause;  for  the  ability  of  nature  to  relieve  herself  by  throwing 
off  sequestra,  &c,  is  sometimes  almost  incredible.  If  the  operation  be 
inevitable,  or  if  the  patient  be  manifestly  failing  day  by  day,  hesitation 
may  become  fatal ;  but  while  the  health  is  kept  up,  and  the  effort  seem  not 
too  great  for  nature  unaided,  expectancy  remains  the  proper  mode  of  treat- 
ment. 

The  inferences  which  have  been  forced  upon  myself  by  a  careful  review  of 
the  cases  above  narrated  may  be  thus  summarily  stated : — 

I.  When  the  injury  is  recent,  in  any  case  of  doubt  the  limb  should  be 
amputated.    For  one  limb  needlessly  lost,  many  lives  will  have  been  saved. 

II.  Resection  in  the  continuity  of  long  bones  is  not  a  substitute  for  am- 


350         Carothers,  Fracture  of  Femur  from  Miuie  Balls.  [April 


putatiou  ;  and  except  in  the  one  case  of  a  bone  projecting  through  the 
skin,  and  otherwise  irreducible,  is  not  an  assistance  to  nature  in  the  treat- 
ment of  compound  fractures. 

III.  Ligation  of  an  artery  above  the  wound  is  too  often  unavailing  as  a 
means  of  checking  secondary  hemorrhage ;  and  in  many,  if  not  most  cases, 
amputation  is  a  safer  remedy. 

IY.  No  secondary  amputation  should  be  performed  for  probable  cause 
only ;  but  if  certainly  requisite,  or  if  the  patient  be  evidently  sinking,  delay, 
even  the  slightest,  is  to  be  deprecated,  and  often  will,  unhappily,  prove 
fatal. 

Philadelphia,  February,  1863. 


Art.  Y. — On  Compound  Comminuted  Fracture  of  the  Femur  from 
Minie  Balls.  By  A.  B.  Carothers,  M.  D.,  of  Newburg,  Cumberland 
County,  Penna.,  and  formerly  Act.  Asst.  Surgeon  U.  S.  Army. 

The  character  and  extent  of  the  injury  caused  by  the  minie  ball  in  the 
bony  tissues,  and  especially  in  the  compact  substance  of  the  shaft  of  the 
long  bones,  as  the  femur,  is  very  different  from  that  caused  by  any  other 
projectile  used  in  modern  warfare. 

The  weight  of  the  ball,  its  velocity,  and  the  great  momentum  resulting 
therefrom,  combined  with  its  rotatory  motion,  serve  to  cause  a  fracture 
differing  from  that  produced  by  the  ordinary  round  ball,  by  the  great  com- 
minution, by  the  disposition  of  the  lines  of  fracture  to  extend  along  the 
bone  in  the  axis  of  its  length,  and  also  by  the  tendency  of  the  fragments 
to  separate  from  their  continuity  and  be  driven  off  into  the  contiguous 
muscles.  I  have  seen  a  transverse  fracture  of  the  femur  caused  by  a  minie 
ball,  at  least  four  inches  above  the  point  at  which  the  ball  impinged  on 
the  shaft  of  the  bone,  resulting  from  momentum  of  the  ball  being  trans- 
mitted along  the  shaft  of  the  bone,  until  a  point  was  reached  at  which  the 
resistance  of  the  femur  counteracted  it,  at  which  point  a  fracture  was 
produced  by  the  opposing  forces. 

It  having  been  my  fortune  to  meet,  during  the  term  of  my  service  in 
the  U.  S.  Army,  quite  a  large  number  of  compound  comminuted  fractures 
of  the  femur  from  minie  balls,  I  purpose  to  give  a  brief  resume  of  the 
cases,  with  a  detail  of  their  treatment  and  results,  as  nearly  as  possible 
from  the  few  hasty  notes  which  I  was  able  to  take  at  the  time,  and  from 
my  own  recollection  of  the  cases. 

My  first  cases  were  three  soldiers  wounded  at  the  battle  of  Cedar  Moun- 
tain, August  9th,  1862,  in  the  U.  S.  General  Hospital  at  Culpepper  Court 
House,  Ya.,  who  were  placed  in  my  ward  as  hopelessly  injured.  They  had  all 
extensive  comminuted  fractures  of  the  middle  and  upper  thirds  of  the  femur. 


1863.]      Carothers,  Fracture  of  Femur  from  Minie  Balls.  351 

They  were  left  at  Culpepper  Court  House  at  the  time  our  forces  under  General 
Pope  retreated  down  the  Yalley  of  Virginia,  on  August  19th,  1862,  and  of 
course  fell  into  the  hands  of  the  enemy.  I  remained  with  them,  and  only 
mention  the  fact,  as  the  insufficient  food,  &c,  which  were  afforded  the  men 
as  prisoners  in  the  hands  of  the  enemy,  and  removed  from  his  base  of  sup- 
plies, must  have  had  a  bearing  on  the  prognosis. 

I  resected  the  femur  in  two  of  the  cases,  taking  out  about  four  inches  of 
the  shaft  from  immediately  below  the  trochanters,  and  in  one  case  cutting 
through  the  trochanter  major. 

They  were  both  fine  subjects,  young  men  in  perfect  health  previous  to 
the  injury,  and  had  neither  been  addicted  to  the  use  of  alcohol.  Both 
died,  worn  out  by  hectic  from  the  extensive  suppuration. 

The  third  was  rather  the  most  promising  case  of  the  three,  and  I  deter- 
mined to  make  an  effort  toward  conservatism.  I  accordingly  placed  his 
limb  on  a  double  inclined  plane,  attended  to  the  external  wound,  keeping 
it  clean,  &c,  pressed  out  the  pus,  which  accumulated  in  considerable  quan- 
tities, and  kept  up  his  general  strength  as  well  as  our  circumstances  would 
allow.  He  recovered  with  a  useful  thigh.  I  regret  that  I  cannot  give 
this  case  more  in  detail,  but  I  was  afterwards  removed  from  him,  and  have 
only  obtained  the  result  from  a  professional  friend. 

The  next  cases  that  came  under  my  observation,  and  partly  under  my 
treatment,  were  sixteen  soldiers  in  the  Waters  Warehouse  Hospital,  George- 
town, D.  C,  under  charge  of  M.  F.  Bones,  Asst.  Surg.  12th  Pa.  Cav. 
They  were  all  wounded  at  the  second  battle  of  Manassas,  August  29th  and 
30th,  1862,  and  had  lain  on  the  field  for  from  eight  to  ten  days,  previous 
to  being  removed,  and  were  consequently  very  much  reduced  in  strength 
by  hunger,  thirst,  loss  of  blood,  suppuration  and  fatigue,  having  been 
brought  forty  miles  in  ambulances,  after  having  lain  so  long  exposed. 
Many  were  nearly  destitute  of  clothing,  and  their  wounds  were  filled  with 
maggots.  These  facts  are  noteworthy,  as  they  have  a  decided  bearing  on 
the  result. 

To  these  cases  were  immediately  applied  Smith's  Anterior  Wire  Splint, 
put  on  by  means  of  broad  adhesive  strips,  which  served  to  suspend  the 
limb;  and  afterwards  the  whole  was  covered  by  a  roller  bandage,  which 
served  to  equalize  the  pressure,  exclude  the  flies,  and  was  removable  at 
pleasure,  without  disturbing  the  support  of  the  limb.  They  had  good 
nutritious  diet,  stimulants,  tonics,  &c,  as  the  cases  required. 

There  was  but  one  operation  performed;  in  which  I  assisted,  which  was 
undertaken  as  a  resection  through  the  trochanters,  but  in  the  course  of  the 
operation  it  was  found  that  the  injury  extended  into  the  head  of  the  femur, 
and  it  was  excised.  This  patient  died  in  a  few  days,  worn  out  by  the  irri- 
tation and  suppuration  consequent  on  so  grave  an  operation. 

The  remaining  fifteen  cases  were  treated  on  the  conservative  plan  I  have 
indicated,  with  five  recoveries  and  ten  deaths,  an  unusually  large  percent- 


352  Carothers,  Fracture  of  Femur  from  Miuie  Balls.  [April 


age,  if  we  consider  the  condition  of  the  men  when  brought  into  the 
hospital. 

The  next  case  was  that  of  ah  officer  in  the  Seminary  Hospital,  George- 
town, D.  C  His  femur  was  badly  comminuted  for  from  four  to  five  inches, 
immediately  below  the  trochanters,  as  a  very  careful  digital  examination, 
with  the  patient  completely  etherized,  revealed.  One  fragment,  apparently 
about  three  inches  in  length,  was  lying  diagonally  across  the  axis  of  the 
thigh,  removed  entirely  from  the  body  of  the  bone  at  one  end,  and  im- 
bedded in  the  muscles  on  the  inner  side  of  the  thigh,  in  apparently  dan- 
gerous proximity  to  the  femoral  vessels.  The  fracture  extended  into  the 
trochanters.  The  operation  of  resection  was  decided  upon  by  the  surgeons 
who  attended  him,  but  from  some  reasons  which  I  never  fully  ascertained, 
but  which  I  think  were  the  objections  of  the  patient  to  losing  his  leg,  it 
was  not  performed,  and  it  was  decided  to  put  his  limb  into  Smith's  anterior 
splint,  and  make  an  effort  to  save  it,  with,  however,  grave  forebodings  for 
the  result. 

A  point  in  this  case  to  which  I  desire  to  direct  special  attention  is,  that 
there  had  been  an  anterior  splint  used  up  to  the  time  when  an  examination 
revealed  so  unfavourable  a  state  of  the  parts,  but  it  had  been  so  adjusted  as 
to  defeat  the  very  intention  with  which  it  had  been  used.  In  consequence  of 
elevating  the  foot  too  much  by  shortening  the  lower  cord  by  which  it  was 
supported,  and  from  placing  the  point  of  support  too  near  the  head  of  the 
patient,  instead  of  making  the  weight  of  the  body  serve  as  an  extending  force, 
the  lower  fragments  of  the  shaft  were  pressed  upwards,  causing  the  ends  of 
the  bone  to  ride  over  each  other,  and  giving  rise  to  a  great  amount  of  pain, 
which  was  entirely  relieved  by  a  proper  adjustment  of  the  splint.  He 
recovered  in  three  months  with  a  useful  thigh,  about  one  and  a  half  inches 
shorter  than  its  fellow,  and  I  had  the  pleasure  of  meeting  him  in  Wash- 
ington a  short  time  since  almost  perfectly  well.  Of  course  he  had  all  the 
advantages  of  good  diet,  stimulants,  tonics,  and  a  careful  attention  to  ge- 
neral symptoms. 

The  last  case  I  have  to  record  was  that  of  a  soldier  in  the  Georgetown 
College  Hospital.  About  the  1st  of  January  ult.  I  was  invited  to  assist 
in  the  operation  of  resection  of  the  femur  for  one  of  these  fractures,  which 
was  done  in  a  masterly  manner,  cutting  through  the  trochanter  major 
about  its  middle  and  removing  about  three  and  a  half  inches  of  the  shaft 
below.  The  loss  of  blood  was  very  small,  and  the  operation  performed  in 
an  unusually  short  time,  but  the  patient  never  reacted  from  the  shock  of 
the  operation,  and  died  within  twenty -four  hours,  although  every  means 
was  resorted  to  to  overcome  the  depression. 

The  result,  therefore,  is,  that  I  present  a  record  of  twenty-one  cases,  in 
the  treatment  of  which  there  were  four  operations,  three  of  resection  of 
the  shaft  of  the  femur  and  one  excision  of  its  head,  all  of  which  terminated 
in  death. 


1863.]      Carot hers,  Fracture  of  Femur  from  Minie  Balls.  353 


In  the  remaining  seventeen  cases,  in  which  no  operation  was  performed, 
but  the  injured  limb  placed  in  an  apparatus  producing  steady  extension 
and  counter-extension,  the  strength  supported  and  the  general  indications 
for  treatment  met,  there  were  seven  recoveries  and  ten  deaths. 

In  the  resections  which  I  performed  I  made  an  effort  to  preserve  the 
periosteum,  and  succeeded  in  a  great  measure,  but  I  never  had  an  oppor- 
tunity to  ascertain  whether  an  effort  at  the  reproduction  of  bone  had  been 
made  by  it  or  not,  although  I  think  it  highly  probable  that  it  was. 

The  operations  were  performed  sixteen  and  seventeen  days  after  the 
reception  of  the  wounds,  and  a  surprising  effort  at  repair  had  been  made  in 
both  cases,  provisional  callus  being  thrown  out  in  great  abundance,  cover- 
ing almost  entirely  some  of  the  fragments  of  bone.  Some  of  the  smaller 
of  these  pieces  were  evidently  dead,  but  had  become  enveloped,  or,  partially 
so,  in  the  large  amount  of  provisional  callus  thrown  out. 

The  argument  used  in  favour  of  resection  was  that  the  operation  and 
subsequent  contraction  of  the  muscles  simplified  the  character  of  the  wound, 
converting  a  compound  comminuted  fracture,  with  the  adjacent  soft  tissues 
filled  with  fragments  of  bone  exciting  irritation  and  suppuration,  into  a 
compound  fracture  merely ;  but  if  we  are  to  have  the  operation  at  all,  I 
think  it  should  be  performed  as  soon  as  possible  after  the  injury,  before  the 
vital  powers  are  exhausted  by  useless  efforts  at  repair.  Let  us  direct  those 
efforts,  if  possible,  toward  the  union  of  the  two  cut  ends  of  bone,  after  the 
operation. 

But  the  more  rational  and  successful  plan  of  treating  this  severe  injury 
appears  to  be  to  bring  as  many  as  possible  of  those  fragments  back  to  their 
continuity  in  the  line  of  the  axis  of  the  shaft,  as  early  as  possible,  before 
provisional  callus  has  been  thrown  out,  interfering  with  a  proper  readjust- 
ment of  the  pieces;  and  allow  them  to  be  united  as  in  an  ordinary  fracture. 
By  so  doing  the  patient  is  also  almost  entirely  relieved  from  the  pain,  which 
is  caused  by  the  pressure  of  the  fragments  upon  the  adjacent  tissues. 

In  fulfilling  the  above  indication,  the  anterior  wire  splint,  applied  by 
means  of  broad  adhesive  strips,  offers  several  apparent  advantages. 

It  can  easily  be  so  adjusted  as  to  produce  any  desired  amount  of  exten- 
sion, the  extending  force  being  so  much  of  the  patient's  body  as  you  suspend 
by  the  splint ;  and  the  force  can  be  increased  or  diminished  at  pleasure  by 
simply  lowering  or  raising  the  splint  by  means  of  the  suspending  cord. 

It  raises  the  injured  thigh  off  the  mattress,  keeping  it  cool,  and  prevent- 
ing accumulations  of  pus,  and  water  if  it  be  used  as  a  dressing,  between  the 
thigh  and  bed,  tending  thus  greatly  to  prevent  excoriations  of  the  skin  of 
the  thigh.  It  affords  an  easy  and  convenient  access  to  the  external  wound, 
and  enables  us  to  cleanse  it  frequently,  thus  preventing  the  accumulation  of 
pus  around  the  nates,  and  the  abrasions  of  skin  resulting  in  troublesome 
and  painful  bedsores,  consequent  on  having  those  parts  bathed  in  irritating 
discharges,  or  at  best  keeping  the  patient  wet,  uncomfortable  and  filthy ;  and 
No.  XC— April  1863.  23 


354  Carothers,  Fracture  of  Femur  from  Mime  Balls.  [April 

lastly,  it  gives  the  patient  a  greater  amount  of  mobility  in  bed  than  any 
other  plan  of  treatment ;  he  can  change  from  one  side  to  the  other  of  his 
bed,  and  after  a  few  weeks,  can  even  be  lifted  with  care,  to  a  chair  by  the 
bedside,  the  limb  remaining  suspended. 

The  principal  objection  to  the  use  of  this  splint  is  that  it  favours  the 
burrowing  of  pus,  which,  from  the  elevated  position  of  the  knee,  will  take 
place  in  the  direction  of  the  pelvis,  and  from  the  arrangement  of  the  mus- 
cles, especially  toward  the  tuber  ischii,  but  this  can  readily  be  prevented  by 
the  judicious  application  of  compresses  and  rollers,  and  counter  openings 
if  necessary,  which,  however,  will  not  often  be  called  for  if  proper  care  has 
been  observed  from  the  outset.  Pus  will  have  no  greater  chance  to  burrow 
than  in  either  of  the  two  other  plans  of  treatment  which  I  shall  mention, 
and  there  are  greater  facilities  for  the  application  of  rollers  and  compresses. 

The  same  indications  can  be  met,  mOre  or  less  perfectly,  in  different  ways. 

The  double  inclined  plane  produces  the  same  results  of  placing  the  frag- 
ments in  a  position  favourable  to  their  union,  and  relieving  the  patient  from 
pain  by  keeping, up  a  regular  degree  of  tension  on  the  comminuted  bone, 
which  can  also  be  increased  or  diminished  at  pleasure  by  increasing  or 
diminishing  the  angle,  but  if  the  external  wound  be  on  the  posterior  part 
of  the  thigh,  it  is  difficult  or  impossible  to  get  at  it  to  cleanse  it,  and  there 
are  all  the  disadvantages  consequent  on  having  the  thigh  and  nates  bathed 
in  irritating  discharges.  Neither  can  the  thigh  be  encircled  with  the 
hands  so  well,  for  the  purpose  of  pressing  out  of  the  external  wound  the 
collections  of  pus  which  are  so  sure  to  accumulate,  and  which  will  burrow 
if  they  do  not  find  exit. 

This  injury  can  also  be  successfully  treated  by  simply  placing  the  patient 
on  his  back  in  bed,  making  extension  by  means  of  a  weight,  cord  and 
pulley,  such  as  is  used  in  the  treatment  of  coxalgia,  and  supporting  the' 
sides  of  the  limb  by  means  of  long  sand-bags.  This  is  an  excellent  plan, 
and  has  been  used  very  successfully,  but  if  the  external  wound  be  on  the 
posterior  surface  of  the  thigh,  the  same  disadvantages  arise  as  in  the  use 
of  the  double  inclined  plane. 

The  evident  deductions  from  the  foregoing  results  appear  to  be :  that 
the  operation  of  resection  is  not  advisable,  but  that  it  offers  a  more  favour- 
able prognosis  as  a  primary  than  as  a  secondary  operation  ;  that  a  moderate 
and  regular  amount  of  extension  and  counter-extension,  combined  with 
attention  to  the  external  wound  in  regard  to  cleanliness,  &c,  preventing 
accumulations  and  burrowings  of  pus  by  securing  it  a  free  exit,  and  by  the 
judicious  use  of  compresses,  supporting  the  general  strength  by  diet,  stimu- 
lants, tonics,  <fec,  and  a  careful  attention  to  general  symptoms,  present  the 
conditions  most  favourable  to  recovery  from  this  grave  injury:  that  it  is 
not  so  uniformly  fatal  as  has  been  heretofore  supposed :  and  lastly,  that 
the  anterior  wire  splint  affords  a  plan  of  treatment  which  gives  to  the 
patient  a  greater  degree  of  ease  and  comfort,  fulfils  the  indications  for 


1863.] 


Peaslee,  Double  Ovariotomy. 


355 


treatment  better,  and  perhaps  affords  a  greater  chance  of  success  and  a 
more  favourable  record,  than  any  other  plan  of  treatment  now  in  use. 

Hoping  that  this  effort  may  induce  others  of  greater  experience  and 
more  extended  observation  to  give  the  results  of  their  observations  and 
their  opinions  of  the  proper  management  of  this  serious  and  terribly  fatal 
injury  to  the  general  advancement  of  surgical  knowledge,  I  respectfully 
submit  it  to  the  notice  of  the  profession. 


Art.  YI. — A  Case  of  Double  Ovariotomy.  Patient  saved  by  daily 
Injections  into  the  Peritoneal  Cavity  for  eight  weeks.  By  E.  R.  Peas- 
lee, M.  I).,  LL.  D.,  Professor  of  Anatomy,  &c. 

Aug.  16,  1862. — Mrs.  E.  L.  S  ,  of  Post  Mills,  Vermont,  consulted 

me  in  regard  to  the  operation,  in  her  own  case,  of  ovariotomy.  She  is  a 
highly  educated  lady,  of  delicate  constitution,  and  thirty-five  years  of  age  ; 
had  been  married  eleven  years,  but  had  never  conceived ;  had  had  an  attack 
of  inflammation  of  the  left  ovary  one  year  after  marriage,  and  had  been 
treated  for  ulceration  of  the  cervix  uteri  two  years  subsequently  to  this 
attack. 

She  first  detected  some  enlargement  of  the  left  side  of  the  abdomen  in 
January,  1860;  and  in  the  following  May,  Dr.  Darnell,  of  Georgia,  in 
which  State  she  was  then  residing,  pronounced  the  enlargement  due  to  an 
ovarian  tumour.  She  returned  to  Vermont  in  December,  1860,  and  was 
tapped  for  the  first  time  in  January,  1861 — 20  lbs.  of  fluid  having  been  at 
that  time  removed.  Up  to  the  present  time  she  has  been  tapped  twenty- 
six  times,  the  amount  of  fluid  varying  between  20  and  30  lbs.  at  a  time. 
For  several  months  past  the  intervals  between  the  tappings  have  been  only 
twelve  to  fourteen  days.  Menstruation  has  continued  regularly  until  its 
cessation  three  months  since.  She  has  not  taken  much  medicine ;  took 
hydragogue  cathartics  for  a  time  with  no  good  result.  Diuretics  did  not 
act  upon  the  kidneys  at  all. 

Present  condition. — Patient  much  emaciated  and  debilitated.  Very 
little  appetite,  as  usual,  when  the  tapping  again  became  necessary.  Girth 
of  abdomen  forty-two  inches.  On  performing  the  operation  of  paracentesis 
to-day,  previously  to  deciding  the  question  as  to  the  propriety  of  the  ope- 
ration of  ovariotomy,  I  removed  21  lbs.  of  fluid,  evidently  from  the  peri- 
toneal cavity;  when  a  large  tumour  could  be  detected,  apparently  presenting 
a  constriction  dividing  it  into  two  portions.  Extensive  adhesions  were 
detected  over  its  anterior  aspect ;  but,  on  the  whole,  the  case  was  con- 
sidered a  favourable  one  for  the  operation  ;  and,  after  stating  its  dangers 
to  the  patient,  she  was  left  to  decide,  after  mature  reflection,  respecting  its 
performance  at  an  early  day. 


356 


Peaslee,  Double  Ovariotomy. 


[April 


An  affirmative  decision  having  been  made,  I  performed  the  operation  on 
the  afternoon  of  the  30th  of  August,  1862,  assisted  by  Dr.  E.  C.  Wor- 
cester, of  Thetford,  Vt,  Dr.  W.  B.  Porter,  of  Paper  Mill  Village,  N.  H., 
and  my  pupils,  Drs.  Cowles,  How,  and  Chapin. 

The  temperature  of  the  apartment  in  which  the  operation  was  to  be 
performed  was  kept  at  80°  (Fahrenheit),  and  the  air  rendered  moist  by  the 
evaporation  of  water.  A  solution  of  common  salt  and  albumen  in  water1 
was  prepared  and  kept  blood  warm,  with  which  to  moisten  the  hands  when 
manipulating  the  tumour  or  other  contents  of  the  abdomen.  The  patient 
was  placed  upon  a  table,  the  pudenda  being  covered  by  a  diaper ;  and  she 
was  kept  under  the  influence  of  Squibb's  sulph.  ether  during  the  operation. 

An  incision  four  inches  long,  extending  equally  above  and  below  the 
middle  point  between  the  umbilicus  and  the  pubes,  was  made  into  the  peri- 
toneal cavity,  when  the  adhesions  before  diagnosticated  were  found.  These v 
were,  however,  peeled  off  by  passing  the  hand  between  the  tumour  and  the 
parietal  peritoneum.  The  tumour  itself,  consisting  of  an  aggregation  of 
sacs,  was  diminished  by  tapping  the  largest  of  them,  till  it  could  be  drawn 
out  through  the  incision,  when  a  double  ligature  was  passed  through  the 
pedicle  and  tied  round  each  half  of  it ;  when  it  was  cut,  and  the  tumour 
removed.  The  tumour  was,  however,  so  completely  sessile  (or  in  such 
complete  contact  with  the  right  side  of  the  uterus)  that  the  ligature  could 
with  difficulty  be  applied ;  and  I  had  to  dissect  it  upwards  from  the  pedicle 
one-half  inch  before  the  latter  could  be  divided. 

There  was  also  an  additional  band  extending  across  from  the  tumour  to 
the  uterus,  which  required  a  third  ligature  to  be  tied  around  it  before  the 
tumour  was  removed.  Still  another  difficulty  presented  itself  which  I  had 
not  encountered  in  previous  operations.  The  tumour  presented  very  many 
vascular  tufts  on  its  external  surface  which  gave  way  from  the  gentlest 
manipulation,  and  this  led  to  a  profuse  hemorrhage  into  the  peritoneal 
cavity. 

Having  removed  the  tumour  just  mentioned,  and  which,  before  reduction 
by  tapping,  was  about  as  large  as  a  gallon  measure,  I  found,  on  passing 
my  hand  into  the  peritoneal  cavity,  that  still  another  tumour  remained. 
This  was  found  to  be  the  left,  as  the  mass  already  removed  was  the  right 
ovary.  It  was  not  quite  half  so  large  as  the  other,  and  was  removed  with- 
out the  occurrence  of  any  hemorrhage ;  its  pedicle  being  also  much  longer 
and  easily  secured  by  a  double  ligature  before  it  was  divided.  All  the  blood 
(and  coagula)  were  then  removed  with  the  greatest  care  from  the  peritoneal 
cavity,  both  by  the  use  of  a  very  fine  sponge  and  by  turning  the  patient 
nearly  upon  the  face,  to  allow  it,  as  well  as  the  dropsical  fluid  which  had 

1  Chloride  of  sodium  giv  ;  albumen  (white  of  eggs)  £vj  ;  water  Oiv.  This  fluid 
nearly  resembles  the  natural  secretion  of  the  peritoneum,  and  was  first  used  by 
me  in  Feb.  1855. 


1863.] 


Peaslee,  Double  Ovariotomy. 


357 


escaped  from  the  sacs,  to  flow  out — the  hands  being  always  dipped  in  the 
artificial  serum  above  mentioned  before  touching  the  internal  parts.  Next, 
the  wound  was  closed  by  eight  silver  sutures  penetrating  the  abdominal 
walls,  peritoneum  and  all — the  five  ligatures  having  been  brought  out 
through  the  lower  extremity  of  the  incision,  A  mere  water-dressing, 
covered  by  oiled  silk,  was  applied  to  the  abdomen,  and  the  patient  was 
placed  in  her  bed  at  six  o'clock  P.  M. 

The  water-dressing  to  be  changed  often  enough  to  keep  it  moist ;  the 
catheter  to  be  used  every  eight  hours ;  the  patient  to  take  only  milk  por- 
ridge every  two  hours  for  the  present ;  and  no  medicine  to  be  given  till 
reaction  is  established,  unless  stimulants  are  required. 

The  following  is  a  condensed  report  of  her  progress  subsequently  to  the 
operation : —        *  * 

9i  P.  M.,  hours  after  the  operation.  Pulse  100,  but  intermittent — 
losing  15  to  30  beats;  respiration  16.  Complains  of  warmth  and  a 
burning  in  the  feet.  Quite  restless,  feels  "very  tired,"  and  has  a  little 
pain.  Had  taken  a  little  milk  porridge  and  a  teaspoonful  of  brandy  at  9. 
10.  o'clock,  still  restless.  Opium  suppository  gr.  j;  ^ijss  urine.  11  P.  M. 
Pulse  a  little  more  regular  ;  respiration  19.  Feels  tired,  but  is  more  quiet. 
Compress  changed.  12  o'clock.  Yery  quiet  and  comfortable.  Reaction 
well-established.  Has  slept  a  little.  Took  some  milk  porridge.  2  A.M. 
Has  been  quiet  during  the  last  two  hours,  and  has  taken  short  naps.  Pulse 
115  to  120,  intermitting  5  ;  respiration  24,  easy  and  regular;  Jijss  urine. 
Took  a  little  porridge.    5  A.  M.  Pulse  120  ;  respiration  24;  urine  ^ij. 

August  31 — morning  after  the  operation. — 7  o'clock.  Has  been  sleeping. 
Pulse  120,  but  slightly  intermittent.  9 \.  Pulse  120,  but  intermits  16; 
respiration  20  ;  pupils  unaffected  by  opium  ;  tongue  slightly  furred ;  skin 
natural;  expression  of  countenance  cheerful.  12.  Pulse  116,  with  ten 
intermissions;  respiration  18.  Elix.  Opii  gtt.  xx.  8  P.M.  She  remains 
about  the  same  as  in  the  morning.  Pulse  120 — intermissions  ten  ;  tongue 
a  little  whiter.  As  thirsty  as  usual  after  being  tapped,  but  no  more  so. 
The  urine  was  drawn  off  at  the  hours  of  10,  4,  and  7 — about  ^ij  each 
time.  Has  taken  elixir  opii  gtt.  x  every  second  hour ;  also,  once  in  two 
hours,  two  tablespoonfuls  of  porridge. 

Monday,  Sept.  1 — Second  day  after  operation. — 8  A.  M.  Pulse  and 
respiration  the  same.  Brandy  3ss.  No  tympanites,  no  increased  tender- 
ness of  abdomen.  Urine  at  12  and  6 — ^ij  each  time.  Has  slept  on  each 
side.  Pupils  natural.  4  P.  M.  Pulse  114,  but  somewhat  irregular;  respi- 
ration 17.  Brandy  Jss.  6 J  P.  M.  Some  pain  with  eructations.  Thinks 
the  brandy  disagrees  with  her.  6  J.  Vomited.  Pil.opiij.  7  P.M.  Has  been 
more  quiet  since  vomiting.  10  P.  M.  A  slight  flow  of  blood  commenced 
from  the  vagina.  12  o'clock.  Respiration  16;  pulse  113,  but  weaker. 
Brandy  3ij. 

Tuesday,  third  day. — 8  A.  M.   Pulse  intermits  every  third  or  fourth 


358 


Peaslee,  Double  Ovariotomy. 


[April 


beat.  Tongue  cleaner.  Says  she  is  comfortable.  Beef-tea  instead  of  the 
porridge.  10  P.  M.  Pulse  118,  intermits  less.  Respiration  20.  Pil.  opii 
per  rectum.  Abdomen  looks  well ;  no  pain  ;  not  much  tenderness  on  pres- 
sure.   She  is  cheerful,  and  the  countenance  wears  a  good  aspect. 

Fourth  day. — 8  A.  M.  Pulse  108,  intermitting  17.  Tongue  quite 
clean,  and  no  irritation  of  stomach.  Has  chewed  a  little  beefsteak,  and 
has  taken  beef-tea  and  brandy  at  intervals.  Vaginal  flow  increasing.  10 
P.  M.  Pulse  112,  but  irregular — losing  one,  two,  and  three  beats.  Counting 
from  each  intermission  it  ran  thus :  3,  3,  8,  19,  34,  3,  3,  4,  9,  17.  Respira- 
tion 20.  Has  been  taking  brandy  3j  every  hour  for  several  hours.  Urine 
increasing  in  quantity ;  skin  natural.    Vaginal  flow  increasing. 

Thursday,  fifth  day. — 8  A.  M.  Pulse  112,  intermissions  12  ;  respiration 
17.  Takes  three  tablespoonfuls  of  beef-tea,  and  brandy  3j,  hourly.  Urine 
increasing  in  quantity ;  catheter  no  longer  required.  Vaginal  discharge 
has  ceased. 

Friday,  sixth  day. — 12|  A.  M.  Had  a  chill  with  cold  sweat  and  "a 
sinking  sensation."  Pulse  104,  and  only  slightly  intermittent.  Brandy 
5ij.    8  A.  M.  Comfortable  again.    Appetite  good.    Wound  dressed. 

Seventh  day. — Pulse  100,  steady  and  no  intermissions.  Had  a  very  good 
night ;  slept  well  without  an  opiate. 

Eighth  day. — Three  stitches  removed.  Wound  suppurating  where  the 
edges  of  the  skin  do  not  meet  (between  the  sutures),  but  the  deeper  parts 
have  adhered.  Pil.  quinise  gr.  j  at  11  o'clock,  and  another  at  5.  A  little 
restless  at  night ;  Pil.  opii  gr.  j. 

Ninth  day. — 8  P.  M.  Had  a  free  alvine  evacuation  spontaneously  at 
noon,  followed  by  some  tenderness  of  the  abdomen.  Opium  suppository 
gr-  j- 

Tenth  day. — 8  A.  M.  Has  taken  during  the  night  tinct.  opii  camph.  ^ss. 
Less  tenderness  of  the  abdomen.  Pulse  110 — intermitting  every  six  or 
eight  beats.    Urine  normal. 

Eleventh  day. — Changed  her  clothing.    The  best  night  yet. 

Thirteenth  day. — Comfortable  since  last  date.  Enema  administered, 
and  bowels  freely  moved.  Sat  up  in  bed  twenty  minutes.  All  the  stitches 
but  two  removed. 

Sixteenth  day. — Comfortable  since  last  date.  Pulse  steady  at  104.  £ij 
clear  fluid  oozed  out  around  the  ligatures  from  the  peritoneal  cavity.  Last 
two  sutures  removed.  8  P.  M.  Bowels  freely  moved.  Some  dizziness. 
Has  taken  no  brandy  during  the  last  two  days,  and  it  was  now  resumed. 

Nineteenth  day. — Was  called  to  see  her  at  1  A.  M.,  because  "  she  seemed 
stupid,  and  it  was  difficult  to  arouse  her."  Quiniae  gr.  ss.,  brandy  3U- 
Although  the  bowels  had  been  freely  moved  by  hydrarg.  cum  creta  and 
rheum,  and  injections  yesterday,  the  dizziness  and  headache  increased.  The 
tongue  was  red,  and  becoming  more  and  more  dry.  Feeling  sure  that  these 
symptoms  were  due  to  the  presence  of  decomposing  fluid  in  the  peritoneal 


1863.] 


Peaslee,  Double  Ovariotomy. 


359 


cavity,  I  decided  to  wash  out  that  cavity.  Accordingly  at  10  P.  M.  I 
passed  an  elastic  bougie  (No.  5)  into  it  by  the  side  of  the  five  ligatures ; 
applied  to  the  tube  a  syringe,  and  injected  a  quart  of  the  artificial  serum 
before  described,  at  a  temperature  of  98°  (Fahren.),  and  then  changing 
the  position  of  the  patient,  and  depressing  the  outer  end  of  the  bougie  so 
as  to  bring  it  to  a  lower  level  than  the  other  extremity  in  the  peritoneal 
cavity — thus  rendering  the  tube  a  syphon — about  three  pints  of  very  fetid 
fluid  were  discharged  in  the  course  of  an  hour. 

As  it  was  found  necessary  to  repeat  this  operation  from  one  to  three 
times  daily  for  the  next  fifty-eight  days,  and,  as  this  was  the  important  and 
peculiar  feature  of  the  case,  I  will  give  the  results  in  as  brief  a  form  as 
possible,  omitting  the  minor  details  of  the  patient's  progress. 

Twentieth  day. — Injected  two  quarts  of  the  solution,  and  it  ran  out 
turbid  and  fetid,  but  not  quite  as  much  so  as  yesterday.  Pulse  106 ;  tongue 
better;  appetite  good.  Liqr.  sodse  chlorinate  gtt.  v,  quaque  sexta  hora 
surnendas.  8  P.  M.  Injected  Oij  of  the  solution,  and  left  it  to  run  out 
through  the  syphon. 

.  Twenty-first  day. — Syphon  has  discharged  during  the  night  Oiij  of  thick, 
creamy-looking,  very  fetid  fluid.  She  feels  better.  Pulse  100  ;  less  thirst 
than  for  several  days  ;  appetite  good.  T  P.  M.  Oij  injected,  and  left  to 
run  out. 

Twenty-second  day. — 10  A.  M.  Slept  well  last  night.  Has  been  passing 
limpid  urine  freely  every  few  hours.  Bowels  moved  once  naturally.  Washed 
out  the  peritoneal  cavity  four  times— injecting  Oj  each  time — and  drawing 
it  out  with  the  syringe.  The  fluid  ran  out  quite  clear  the  last  time.  7 
P.  M.  Ojss  of  the  solution  injected  at  once  and  left  to  flow  out.  It  had 
very  little  odour,  but  the  operation  was  repeated  in  the  evening. 

Twenty-third  day. — 10  A.  M.  Pulse  110,  and  good.  Two  semi-fluid 
evacuations  from  the  bowels  since  last  report.  Tinct.  opii  camph.  3j. 
Appetite  good.  While  introducing  the  tube  a  fetid  gas  escaped  through 
it.  Injected  as  usual,  but  the  fluid  that  came  away  was  not  very  fetid. 
Pulse,  after  injection,  104.  8  P.  M.  Before  injecting,  applied  the  syringe 
to  the  tube  and  drew  off  Oj  of  somewhat  fetid  fluid  ;  then  injected  Ojss,  and 
left  to  flow  out  through  the  syphon.  Pulse  before  injecting  110;  after- 
wards 104.    Best  day  yet. 

(The  bowels  were  moved  naturally  once  a  day  after  this  date.) 

Twenty-fourth  day. — 10  A.  M.  Drew  off  Oss  of  thick,  creamy-looking 
fluid,  by  suction  with  the  syringe.  Then  injected  as  before.  8  P.  M.  Drew 
off  ^iv,  very  nearly,  of  thick  fluid — not  fetid,  but  quite  offensive.  Then 
injected  as  before. 

Twenty-fifth  day. — A.  M.  The  fluid  drawn  off  by  the  syphon  last  night 
was  quite  transparent.  Injected  Ojss,  and,  on  raising  her  up  in  bed,  a 
somewhat  thicker  fluid  came  awaj.    Tinct.  opii  camph.  3j-    8  P.  M.  She 


360 


Peaslee,  Double  Ovariotomy. 


[April 


was  fatigued  by  the  prolonged  operation  of  the  morning,  but  is  better  now. 
Fluid  comes  away  clearer  after  the  injection. 

Twenty-sixth  day. — A.  M.  Pulse  100,  good  ;  tongue  do.  Syphon  fluid 
clearer  during  the  night,  ^iij  drawn  by  suction — offensive,  but  thinner. 
No  gas  escapes  around  the  tube.  One  ligature,  the  highest  on  the  pedicle 
of  the  left  side,  removed. 

Twenty -seventh  day. — About  ^iv  of  the  thick  fluid  by  suction  ;  but  gij 
of  the  solution  was  injected  and  left  in  last  night.  Hitherto  the  tube  had 
been  removed  each  time  after  being  used,  but  as  the  opening  through  the 
abdominal  wall  was  getting  smaller,  and  as  the  introduction  of  the  tube 
was  beginning  to  cause  considerable  pain,  it  was  now  allowed  to  remain  in, 
and  was  seldom  afterward  removed  during  the  entire  period  of  her  con- 
valescence. Being  satisfied  also  that  the  albumen  in  the  solution  under- 
went decomposition  on  commixture  with  the  fetid  fluid  in  the  peritoneal 
cavity,  I  henceforth  used  the  following  solution  :  R.  Liqr.  sodse  chlorinatse 
f3j,  sodii  chloridi  3j,  aquas  Oj.  M. — instead  of  the  one  before  mentioned  ; 
and  I  had  reason  to  be  perfectly  satisfied  with  the  change. 

Twenty -eighth  day. — Fluid  drawn  out  clearer  and  odourless.  Says  she 
has  noticed,  during  the  last  two  or  three  days,  an  escape  of  air  from  the 
vagina  in  puffs,  and  also  a  whitish  discharge,  about  one  drachm,  three 
times  a  day,  for  about  one  week.  I  feared  the  fetid  accumulation  in  the 
abdomen  had  caused  ulceration  through  the  vaginal  wall,  but,  on  examina- 
tion, found  this  was  not  the  fact. 

Twenty-ninth  day. — A.  M.  Passed  a  good  night,  £ij  of  odourless  but 
thick  fluid  by  suction.    P.  M.  3j  by  suction.    Injected  fluid  ran  off  clear. 

Thirtieth  day. — Pulse  about  the  same,  104.  The  tube  causes  some  irri- 
tation, and  about  3j  of  healthy  pus  has  been  discharged  around  it.  ^iij  of 
the  creamy  fluid  by  suction,  but  there  is  no  offensive  odour.  Other  liga- 
tures not  loose  yet. 

At  this  time  I  returned  to  New  York,  leaving  Mrs.  S.  under  the  care  of 
Prof.  Albert  Smith,  of  the  N.  H.  Medical  Institution,  and  to  him  and  to 
the  husband  of  the  patient  I  am  indebted  for  the  remainder  of  this  report. 
I  advised  them  to  continue  the  injections  daily,  once  or  twice  according  to 
the  character  and  the  quantity  of  the  fluid  removed,  and  as  long  as  it  con- 
tinued to  be  fetid.  This  was  done ;  the  patient  always  feeling  an  immediate 
benefit  from  each  washing  out,  and  relapsing  into  a  languid  state  if  the 
operation  was  omitted  or  too  long  deferred. 

Sept.  30.  A.  M.  pulse  100;  gij  of  the  peculiar  fluid  by  suction,  and  in 
the  evening  a  like  amount.    Sat  up  in  bed  to  eat,  for  the  first  time. 

Oct.  6.  The  amount  of  fluid  in  the  abdomen  has  been  slowly  decreasing; 
only  gjss  has  accumulated  in  twenty-four  hours. 

\Mh.  The  abdominal  walls  have  contracted  to  such  an  extent  that  only 
3ij  of  the  dilute  solution  of  chlorinated  soda  can  be  conveniently  injected 


1863.] 


Peaslee,  Double  Ovariotomy. 


361 


and  retained.  Since  the  6th  inst.  the  experiment  has  been  tried  of  drawing 
out  all  the  matter  and  omitting  the  injection ;  but  the  fetor  increased  to 
such  an  extent  that  the  solution  of  soda  was  resorted  to  again.  Sat  up 
to-day  in  a  chair  half  an  hour.  Pulse  100.  Appetite  good.  Bowels  con- 
stipated for  several  days ;  moved  by  enema.  Pil.  rhei  comp.  iij  produced 
no  effect. 

21th.  Sits  up  an  hour  or  two  at  a  time,  and  walks  across  the  room 
once  or  twice.    Only  3j  of  thick  fluid  removed  by  suction.    Pulse  98. 

28th.  Fifty-ninth  day. — She  was  placed  on  a  mattress  in  a  covered  car- 
riage to-day,  and  carried  to  her  home,  twelve  miles  distant.  The  journey 
caused  some  fatigue,  but  otherwise  no  inconvenience. 

Nov.  6.  Remaining  four  ligatures  were  removed.  Mr.  Smith  remarks 
in  a  letter:  "I  think  they  were  held  by  the  knot  on  the  inner  side  of  the 
abdomen,  as  pulling  has  caused  no  pain  for  a  week  past." 

From  this  time  onward  she  gained  gradually  in  strength,  her  convales- 
cence being  interrupted  only  by  a  severe  attack  of  constipation  and  colic, 
which  caused  no  little  apprehension,  but  she  was  very  skilfully  treated  by 
Dr.  Worcester  (before  mentioned),  and  finally  relieved.  Less  and  less 
matter  was  drawn  from  the  peritoneal  cavity  until  Nov.  14th,  when  none 
whatever  could  be  obtained. 

On  the  16th  of  November,  seventy-eight  days  after  the  operation,  her 
husband  writes:  "With  the  consent  of  Dr.  Worcester,  I  have  this  morning 
removed  the  tube  and  closed  up  the  opening.7'  The  injections  had  thus 
been  used  for  fifty-nine  days  in  succession,  or  from  the  nineteenth  to  the 
seventy-eighth  day  after  the  operation. 

Jan.  1,  1863.  Mrs.  S.  wrote  me  to  present  the  compliments  of  the  sea- 
son, and  said  she  had  as  few  aches  and  pains  as  the  majority  of  people 
have;  and  up  to  the  13th  of  March  I  hear  of  her  continuing  in  good 
health. 

Remarks. — 1.  Successful  cases  of  double  ovariotomy  are  very  rare.  The 
first  case  reported  in  this  country,  I  think,  was  one  of  my  own ;  the  ope- 
ration having  been  performed  nearly  twelve  years  previously  to  the  one 
now  under  consideration.  In  that  instance1  the  patient  was  24  years  old, 
and  unmarried ;  and  it  may  not  be  uninteresting  to  add  here,  by  way  of 
completing  the  record  of  that  case,  that  she  married  about  a  year  after 
the  operation;  that  she  has,  of  course,  never  menstruated  since  that  time, 
nor  conceived.  She  has,  however,  enjoyed  uniform  good  health,  never 
having  had  even  headaches,  periodical  or  otherwise.  With  the  two  excep- 
tions above  specified,  she  is  capable  of  fulfilling  all  the  functions  attributable 
to  her  sex.  Neither  her  external  physical  conformation  nor  her  mental 
characteristics  have  undergone  any  change  in  consequence  of  the  absence 


See  this  Journal  for  April,  1851. 


362 


^   Peaslee,  Double  Ovariotomy. 


[April 


of  the  ovaries.  She  is  in  all  respects  now,  at  the  age  of  36,  a  splendidly 
developed  woman. 

2.  The  use  of  large  injections  into  the  peritoneal  cavity  has  never  been 
before  resorted  to,  so  far  as  I  am  aware,  except  in  a  case  of  my  own,  re- 
ported in  this  Journal1  seven  years  ago.  It  became  quite  evident  after  ten 
days'  use  of  the  injections,  that  this  patient's  life  might  be  prolonged,  other 
circumstances  itemaining  unchanged,  so  long  as  the  peritoneal  cavity  was 
kept  thoroughly  cleansed.  But  it  became  at  length  a  source  of  anxiety  to 
know  when  this  necessity  might  cease  to  exist.  During  the  last  week  of 
their  application  before  I  left  the  patient  (i.  e.  up  to  the  seventeenth  day 
of  their  use),  the  quantity  and  the  quality  of  the  fluid  in  the  cavity  had 
undergone  but  very  little  change.  In  my  first  case  the  injections  were  con- 
tinued for  only  seven  days.  In  the  present  case  they  were  finally  found  to 
be  required  from  one  to  three  times  daily,  for  fifty-nine  days  in  succession. 
In  that  case  I  always  used  the  artificial  serum  before  described ;  in  this  case 
the  albumen  in  it  underwent  decomposition,  and  a  solution  of  common  salt 
and  chloride  of  soda  was  found  not  to  be  liable  to  this  objection. 

3.  I  have  no  hesitation  in  attributing  the  recovery  of  this  patient  (as 
well  as  that  of  the  one  just  alluded  to)  to  the  use  of  the  peritoneal  injec- 
tions. The  recurrence  of  the  grave  symptoms  was  so  certain  and  so  rapid, 
whenever  they  were  too  long  delayed,  as  to  leave  no  doubt  on  this  point. 
Nor  do  I  doubt  that  death  has  occurred  after  many  unsuccessful  operations 
of  ovariotomy,  from  the  presence  of  decomposed  fluid  in  the  peritoneal 
cavity.  Had  I  not  resorted  to  this  expedient,  I  am  confident  I  should  have 
lost  two  cases  out  of  five.  Having  done  so,  all  my  cases,  up  to  the  present 
time,  have  been  successful.  Of  course  the  liability  to  such  accumulations 
of  fetid  fluid  is  confined  more  exclusively  to  cases  of  ovarian  tumours  com- 
bined with  ascites.  Both  of  my  cases  were  of  that  class.  It  is  deemed 
important  to  recognize  this  cause  of  a  fatal  termination  of  the  operation 
under  consideration,  and  to  have  demonstrated  the  practicability  of  its 
removal. 

4.  It  is  interesting  to  notice  the  tolerance  of  a  decomposed  fluid  in  con- 
tact with  it,  which  was  manifested  in  this*  case  by  the  peritoneum.  The 
fluid  gradually  accumulated  to  not  less  than  a  gallon,  and  was  excessively 
fetid;  yet  no  decided  symptoms  of  poisoning  manifested  themselves  till  the 
nineteenth  day  after  the  operation.  This  shows  that  absorption  from  the 
diseased  peritoneal  surface  is  very  slow ;  though  it  also  appeared  that  it 
becomes  more  rapid  when  the  poison  has  once  entered  the  circulation.  And 
hence  the  necessity  of  removing  the  fluid  daily,  till  all  excess  of  the  perito- 
neal secretion  and  all  decomposition  have  subsided. 

5.  The  vaginal  flow  which  occurred  forty-eight  hours  after  the  operation 
and  continued  sixty  hours,  must  not  be  accepted  as  an  attempt  at  menstru- 


1  See  the  No.  for  Jan.  1856. 


1S63.]      Fraser,  Analysis  of  Ninety-three  Cases  of  Labour.  363 


ation.  It  occurred  in  the  first  of  my  cases  also,  and  is  merely  a  hemorrhage 
resulting  from  the  uterine  congestion  produced  by  the  ligatures.  It  is,  how- 
ever, a  favourable  sign,  since  by  relieving  congestion,  it  diminishes  the 
probability  of  the  supervention  of  inflammation  after  the  operation.  A 
free  secretion  of  urine  is  also,  in  this  sense,  a  favourable  symptom. 

6.  I  have  also  used  the  gum  elastic  bougie  as  a  syphon,  in  the  operation 
of  paracentesis  thoracis.    The  fluid  is  thus  most  thoroughly  removed. 

7.  I  still  attach  importance  to  the  use  of  the  artificial  serum  in  ovari- 
otomy ;  and  to  the  elevated  temperature  and  moisture  of  the  air  of  the 
apartment,  on  opening  the  peritoneal  cavity. 

8.  I  prefer  the  ligature  to  the  clamp  in  all  cases.  In  the  present  case 
the  latter  could  not  possibly  have  been  applied  to  the  right  pedicle ;  and  I 
know  of  no  case  in  which  either  the  clamp  is  for  any  valid  reason  to  be 
preferred,  or  the  ligatures  are  for  any  valid  reason  objectionable.  Both  are 
used  to  prevent  hemorrhage;  and  certainly  the  latter  are  more  reliable  than 
the  former  in  this  point  of  view.  And  if  the  clamp  is  sooner  detached,  the 
ligatures,  on  the  other  hand,  do  no  harm  by  remaining.  In  one  of  my 
cases  a  ligature  remained  four  and  a  half  months  without  producing  the 
least  sign  of  inflammation,  or  irritation  even,  of  the  peritoneum.1  It  was 
doubtless  held,  during  most  of  the  time,  by  granulations  in  the  abdominal 
walls.  I  make  the  ligature  of  three  threads  of  saddlers'  silk,  waxed,  but 
not  twisted. 

9.  The  use  of  powerful  narcotic  doses  (as  advised  by  some)  during  the 
first  two  or  three  days  after  the  operation,  I  consider  unjustifiable. 

New  Yokk,  March,  1863. 


Art.  VII. — Analysis  of  Ninety -three  cases  of  Labour  which  came  under 
the  care  of  the  Author.  By  James  IN".  Fraser,  M.  D.,  L.  R.  C.  S.  Edin- 
burgh, of  St.  John's,  Newfoundland.  (Communicated  to  the  "Boston 
Society  for  Medical  Improvement.") 

I.  TJje  number  of  cases. — The  total  number  of  cases  was  ninety-three, 
not  including  any  cases  of  miscarriage.  It  must  be  understood,  however, 
that  these  do  not  represent  ninety-three  different  women,  as  some  of  the 
patients  came  under  my  care  two  or  more  times. 

II.  The  ages  of  the  women. — The  total  ages  of  the  women  amounted 
to  2,645  years,  the  average  age  for  each  being  28  J  years.    The  following 

1  In  this  case  also  the  bougie  remained  almost  constantly  for  fifty-one  days 
(from  the  27th  to  the  78th). 


364         Fraser,  Analysis  of  Ninety-three  Cases  of  Labour.  [April 


table  exhibits,  in  detail,  the  number  of  patients  delivered,  with  their  respect- 
ive ages : — 


Ages  of 

Number  of 

Ages  of 

tlie  women. 

women. 

tlie  women. 

91  uonrQ 

AtL  J  Cello  • 

22  « 

1 

Oii  VCtlLo 

33  " 

!       *.  4 

23  " 

35  " 

24  " 

.    •  .  4 

36  H 

25  " 

7 

37  " 

26  « 

13 

38  " 

27  " 

4 

40  " 

28  " 

15 

44  " 

29  " 

8 

45  « 

30  " 

5 

31  \l 

3 

Total, 


Number  of 
women. 

7 

'  2 
1 
5 
1 
1 
1 
1 
1 

93 


III.  The  duration  of  labour. — The  total  duration  of  labour,  calculating 
as  precisely  as  I  could  from  the  first  commencement  of  the  pains,  amounted 
to  1,249  hours.  The  average  duration  of  each  case  was  13J  hours,  being 
half  an  hour  longer  than  the  average  duration  in  311  cases  occurring  in 
the  Edinburgh  Maternity  Hospital,  and  recorded  by  Professor  Simpson,  of 
Edinburgh. 

The  following  table  shows  the  duration  of  the  whole  labour  in  each 

case : — 


Duration  in  hours. 

>  .   .   1  .. 

11  • 

2  . 
2*  . 

3  . 

4  . 
4i  . 

5  . 

6  . 
7 

8  . 

9  . 

10  . 

11  . 

12  . 


Cases  of  labour. 

in  1  case 

1  " 

2  cases 
2  " 

2  " 
8  " 

1  case 

2  cases 
10  " 

3  " 

4  " 

5  " 
2  " 
2  " 

13  " 


Duration  in  hours. 

13 
14 
15 
16 
18 
20 
23 
24 
25 
26 
36 
42 
48 

60 


Cases  of  labour. 

in  1  case 
8  cases 
2  " 
1  case 

1  " 

2  cases 
1  case 

10  cases 

1  case 

2  cases 

3  " 

1  case 
1  " 


TV.  The  number  of  pregnancies. — The  total  number  of  pregnancies 
for  the  niiiety-three  women  (not  including  miscarriages,  of  which  I  have 
no  information)  amounted  to  175 — the  average  number  being  1J,  and  the 
percentage  188J§.  The  following  table  exhibits  the  number  of  cases,  with 
the  corresponding  number  of  the  pregnancy  in  each  ;  by  which  it  will  also 
be  observed  that  first  deliveries  constitute  one-third  of  the  whole  : — 


Number  of 
the  pregnancy. 

1 

2 
3 
4 
5 
6 


Number  of 
women. 

31 
25 
13 
11 

4 

5 


Number  of 
the  preguaucy. 


11 


Number  of 
women. 

1 

2 


Total,  93 


1863.]      Fraser,  Analysis  of  Ninety-three  Cases  of  Labour.  365 


V.  The  number  of  children.— -The  children  resulting  from  the  93 
labours  at  the  full  time  (with  the  exception  of  two  premature  cases)  were 
99  in  number.    Of  these,  there  were  born — 


In  single  births 
In  twin  " 


Total, 


87 
12 

99 


VI.  The  sex  of  the  children. — Of  the  ninety-nine  children,  53  were 
males  and  46  females ;  or,  5?  per  cent,  of  the  former  and  49  jf  of  the  lat- 
ter: of  the  whole  number,  106^f  per  cent.  These  facts,  with  the  propor- 
tion and  percentage  of  still-births,  are  exhibited  in  the  following  table  : — 


Sex  of  the 

No.  of 

No.  horn 

No.  born 

Proportion  of 

Per- 

child. 

children. 

alive. 

dead. 

still-births. 

centage. 

Male 

53 

47 

6 

1  in  every  9 

Female  . 

46 

40 

6 

1  in  every  8 

13^3 

Total, 

99 

87 

12 

1  in  every  8 

12/, 

Of  these  still-births  there  were  born- 

Under  cranial  presentations 
"  breech  " 
"  hand  " 
"  elbow  " 
"  shoulder  " 
"     side  " 


Total,  12 


In  one  of  the  cases  of  still-birth  under  cranial  presentation  the  cord  was 
wound  thrice  around  the  child's  neck ;  in  two  others  delivery  was  preceded 
by  uncontrollable  vomiting ;  in  one  of  these  labour  was  premature.  In  a 
fourth,  delivery  was  effected  by  craniotomy.  In  one  of  the  cases  under 
breech  presentation  the  mother  had  convulsions  during  labour ;  in  the 
second  there  was  prolapse  of  the  cord.  In  the  case  of  shoulder  presenta- 
tion labour  was  premature ;  and  in  that  of  the  side  there  was  prolapse  of 
the  cord.  In  the  case  of  elbow  presentation  the  child  was  a  twin  male. 
None  of  the  children  were  born  putrid. 

VII.  The  modes  in  which  the  children  presented. — The  following  table 
shows  in  detail  the  different  kinds  of  presentation,  and  the  number  of  each 
respectively,  with  the  percentage  : — 


Presentation. 

Head  . 
Breech 
Hand  . 
Elbow 
Shoulder 
Foot  . 
Face  . 


No.  of  cases. 

.  85 

.  4 

.  1 

.  1 

.  1 

.  1 

.  1 


Percentage. 

851f 

i9V 


Presentation.    No.  of 

Side  (left) 
Head  and  hand 
Breech  and  cord 
Side  and  cord 
Head  and  cord 


Percentage. 
I* 


"  Total,  99  cases. 

There  was  not  a  case  of  presentation  of  placenta,  partially  or  entire. 


366 


Fraser,  Analysis  of  Ninety-three  Cases  of  Labour. 


[April 


YIIL  Plural  births. — Out  of  the  ninety-three  cases  6  women,  or  1  in 
every  15,  gave  birth  to  twin  children,  which  appears  to  me  to  be  a  very 
high  average.  The  percentage  in  these  cases  amounted  to  6J|.  The  fol- 
lowing table  exhibits  the  state  and  presentations  of  the  twelve  children  in 
the  six  twin  cases  : — 

No.  of  children    No.  of  children 
Presentation.  A  o.  of  cases.        born  alive.  horn  dead. 

Double  cranial  presentation     .3  6  0 

1st  child,  foot ;  2d  child,  head  12  0 

1st  child,  head;  2d  child,  breech  12  0 
1st  child,  head;  2d  child,  elbow  111 

Total,  6  cases,  or  11  1 

"     '       12  children. 

The  average  mortality  in  the  twin  cases  was  1  in  12,  and  the  percentage 
8J.    The  sexes  of  the  twin  children  were  as  follows 

In  2  cases,  both  children  male 
In  2  cases,  both  children  female  . 
In  2  cases,  1st  child  male,  2d  child  female  . 


Total,  6  cases.  12 

Thus  in  the  twin  cases  there  was  an  equal  number  of  male  and  female 
children. 

IX.  The  mode  of  delivery. — The  following  table  shows  the  number  and 
percentage  of  those  delivered  naturally  and  by  artificial  means  : — 


Mode  of  delivery. 

No.  of  cases. 

Percentage. 

Proportion. 

By  natural  pains  . 

75 

80f| 

1  in  l\ 

By  artificial  means 

24 

25§f 

lin4 

Mode  of  artificial  delivery. 

By  podalic  version 

4 

411 

1  in  23 

By  cephalic  version 

1 

1  in  93 

By  forceps  . 

18 

mi 

1  in  5 

By  craniotomy 

1 

1  in  93 

Turning  was  adopted  in  three  cases  for  preternatural  presentations,  and  in 
one  where  labour  was  premature,  and  was  preceded  by  uncontrollable  vomit- 
ing; in  this  case  the  head  was  almost  beyond  reach,  and  great  difficulty  was 
experienced  in  attempting  to  apply  the  forceps;  consequently,  turning  was 
had  recourse  to  in  order  to  hasten  delivery.  In  the  case  of  cephalic  version 
labour  was  premature,  and  the  foetus  was  malformed. 


X.  The  instrumental  deliveries. — It  will  be  observed  from  the  foregoing 
table  that  the  forceps  were  used  in  an  unusually  large  proportion  of  cases, 
and  my  principal  object  in  drawing  up  these  papers  is  to  show  the  utility 
and  comparative  safety  in  the  early  and  careful  application  of  these  instru- 
ments, unless  there  be  some  positive  contraindication  to  their  use.  It  will 
be  seen  by  referring  to  the  general  statistical  table,  that  all  the  mothers 


1863.]      Eraser,  Analysis  of  Ninety-three  Cases  of  Labour.  367 

delivered  by  the  forceps  recovered,  and  only  two  of  the  children  delivered 
by  the  same  means  were  born  dead ;  and  in  one  of  these  cases  labour  was 
premature,  and  in  the  other  of  sixty  hours'  duration ;  so  that  in  neither 
case  can  the  death  of  the  child  be  attributable  to  the  use  of  instruments. 
I  dare  say  that  in  some  of  these  cases  the  administration  of  ergot  and  the 
use  of  other  stimulating  means  might  have  been  sufficient  to  effect  delivery; 
but  I  believe  the  adoption  of  such  measures  would  be  more  likely  to  prove 
injurious  to  both  mother  and  child  than  the  early  and  careful  use  of  the 
forceps,  as  labour  would  thereby  be  prolonged  and,  consequently,  the  dan- 
ger to  mother  and  child  become  greater ;  there  would  also  be  a  greater 
probability  of  complications  arising.  These  views,  I  think,  are  borne  out 
by  the  following  recognized  principles  in  midwifery  :  1.  "  The  maternal 
mortality  attendant  upon  parturition  increases  in  a  ratio  progressive  with 
the  increased  duration  of  labour.  2.  The  infantile  mortality  attendant  upon 
parturition  increases  in  a  ratio  progressive  with  the  increased  duration  of 
labour.  3.  The  mortality  to  the  infant  and  mother  is  tenfold  greater  in 
labour  prolonged  than  in  labour  terminated  within  twenty -four  hours. 

4.  The  liability  to  most  of  the  morbid  complications  connected  with  labour 
becomes  increased  in  proportion  as  the  labour  is  increased  in  duration. 

5.  The  danger  of  instrumental  delivery  depends  more  upon  the  previous 
duration  of  labour  than  upon  the  operation  employed."  (Professor  Simp- 
son's Lectures,  1851-52.)  Now  it  will  be  observed  (general  statistical 
table)  that  where  the  forceps  were  used  labour  was  completed  within  twenty- 
four  hours  in  two-thirds  of  the  cases,  and  no  injurious  after-effects  followed 
in  any  of  these  cases ;  and  convalescence  was  protracted  in  only  two  of  the 
whole  number.  In  one  of  these  cases  the  patient  suffered  from  ante  and 
post-partum  hemorrhage,  and  miscarried  about  six  months  prior  to  delivery, 
there  having  been  twin  conceptions,  one  foetus  dying.  The  other  was  a 
case  of  twin  labor,  where  one  child  presented  by  the  elbow  and  was  turned, 
so  that  in  this  case  the  injurious  after-effects  were  more  likely  owing  to  the 
manual  than  to  the  instrumental  interference.  In  my  practice  I  have  not 
confined  myself  to  the  rules  and  regulations  so  specially  laid  down  in  some 
obstetrical  works  for  our  guidance  in  the  use  of  the  forceps,  nor  do  I  believe 
these  to  be  so  essential  or  of  so  much  importance  as  they  are  said  to  be. 
I  may  remark  that  I  have  always  used  Simpson's  long  forceps. 

Craniotomy  was  had  recourse  to  in  one  case  where  the  head  of  the  child 
was  arrested  at  the  "brim,"  in  consequence  of  contraction  of  the  conjugate 
diameter.  In  this  case  I  first  tried  to  deliver  by  turning — brought  down  a 
foot,  but  completely  failed  in  delivering.  I  have  a  full  record  of  the  case, 
which  I  will  be  happy  to  communicate  if  thought  of  sufficient  value. 

XL  Hie  complicated  labours  — The  following  table  contains  a  list  of 
the  complications  observed  in  the  foregoing  cases/with  the  respective  num- 
bers, proportion,  and  percentage  of  each.    There  are  four  cases  of  "slight 


368         Fraser,  Analysis  of  Ninety-three  Cases  of  Labour.  [April 

disproportion"  mentioned  in  the  table — such  a  condition  ought  not,  per- 
haps, strictly  speaking,  to  be  considered  as  a  "complication" — nevertheless 
they  were  cases  where  I  thought  it  advisable  to  use  the  forceps  at  an  early 
stage  of  labour. 


Complication.  No. 

of  cases. 

Proportion. 

Percentage. 

Convulsions  

2 

1  in  46£ 

m 

Hemorrhage  .... 

3 

1  in  31 

q  7 

Puerperal  fever 

4 

1  in  23 

Contraction  at  brim 

3 

1  in  31 

q  7 

Inertia  of  uterus  . 

4 

lin  23 

m 

Rigidity  of  os 

2 

1  in  46£ 

m 

Syncope         .  . 

2 

1  in  46£ 

m 

Malpresentation 

6 

1  in  15 

Uncontrollable  vomiting 

2 

1  in  46£ 

Slight  disproportion 

4 

lin  23 

m 

Prolapse  of  cord  . 

3 

1  in  31 

Q  7 

Total, 

35 

37ff 

I  omitted  mentioning  that  one  of  the  mothers  died ;  in  this  case  there 
was  an  extremely  torpid  state  of  the  bowels,  which  could  not  be  brought 
into  action  by  any  means.  This  serious  condition  was  followed  by  alarm- 
ing and  uncontrollable  vomiting,  which  persisted  for  four  or  five  days. 
Labour,  which  was  premature,  supervened,  and  to  hasten  delivery  the  child 
was  turned  ;  but  the  patient  died  twenty-eight  hours  afterwards.  I  am  of 
opinion  that  the  fatal  issue  was  not  consequent  upon  parturition,  but  was 
the  result  of  prior  prostrating  causes.  In  conclusion,  I  have  only  to  ob- 
serve that  the  ninety-three  cases  of  labour  were  recorded  consecutively  as 
they  occurred  in  my  practice,  none  having  been  selected;  therefore,  the 
data  upon  which  the  preceding  calculations  have  been  based  may  be  relied 
upon,  as  all  the  patients  came  under  my  own  immediate  care  and  observa- 
tion, and  the  particulars  regarding  them  were  recorded  at  the  time  of  their 
occurrence. 

P.  S.  I  have  to  acknowledge  my  indebtedness  to  Professor  Simpson's 
obstetric  works  (first  series)  for  the  construction  of  most  of  the  preceding 
tables. 


1863.]     Fraser,  Analysis  of  Ninety-three  Cases  of  Labour,  369 


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D  a  v  I  e  s ,  Silver  Wire  Ligatures. 


373 


Art.  VIII. — On  Silver  Wire  Ligatures.  Read  before  the  Brodie  Med.- 
Clrir.  Society,  Frederick  City,  Md.,  Dec.  1862.  By  Redfern  Davies,  of 
Birmingham,  England,  now  acting  Assist.  Surgeon,  TJ.  S.  A. 

In  the  summer  of  1858,  being  desirous  of  healing  a  vesico -vaginal  fistula 
of  very  large  size,  I  carried  out  exactly  the  operative  measures  advocated 
by  Dr.  Marion  Sims.  But  whether  from  the  size  of  the  fistula,  from  defect 
in  applying  his  silver  clamps  and  wires,  or  from  some  bungling  in  the  ope- 
ration, I  failed  completely,  although  I  was  at  the  same  time  perfectly 
satisfied  with  the  behaviour  both  of  the  clamps  and  wires. 

Three  years  ago,  having  to  treat  a  bad  case  of  elephantiasis  of  the  leg, 
I  followed  the  means  of  cure  first,  I  believe,  both  proposed  and  carried  out 
by  Dr.  Carnochan.  His  plan  of  treatment  consisted  in  cutting  off  the  main 
arterial  supply  of  blood  to  the  limb,  by  tying  the  femoral  artery  at  the 
apex  of  Scarpa's  triangle.  But  deeming  that  I  should  effect  the  same  result 
by  tying  the  popliteal  artery,  and  by  reason  of  its  being  further  removed 
from  the  trunk  of  the  body,  obviate  some  of  the  dangers  attendant  upon 
ligaturing  the  femoral,  I  tied  the  popliteal  artery,  and  with  a  silver  wire 
for  a  ligature.  This  came  away  on  the  twenty-first  day,  and  the  result  of 
the  operation  was  an  almost  complete  diminution  of  the  size  of  the  limb 
to  its  natural  dimensions. 

I  would  particularly  draw  the  attention  of  this  meeting  to  this  case, 
because  it  has  been  considered,  both  in  New  York  and  here,  that  though 
silver  wire  may  be  useful  in  tying  arteries  after  amputations,  it  is  not 
advisable  to  do  so  in  their  continuity.  The  best,  most  concise,  and  accu- 
rate description  of  the  effects  produced  upon  an  artery  by  its  ligation,  that 
I  know  of,  is  in  "Mr.  Guthrie's  Commentaries  on  the  Surgery  of  the 
War."    He  says: — 

"  Where  a  round  and  small  ligature  is  properly  applied  to  an  artery  of  a  large 
size,  such  as  the  femoral,  the  sides  of  the  vessel  are  brought  together  in  a  folded, 
plaited,  or  wrinkled  manner ;  the  ancient  middle  and  inner  coats  of  the  artery, 
including  the  modern  four,  are  divided,  while  the  outer  one  remains  entire  and 
apparently  unhurt. 

"If  the  ligature  be  removed,  an  impression  or  indentation,  made  by  it  on  the 
artery,  will  remain  as  a  mark ;  and  if  the  artery  be  slit  open  in  a  careful  manner, 
the  division  of  the  inner  coats  will  be  obvious." 

And  again,  he  says  : — 

"  The  inner  and  middle  coats  formed  by  four  distinct  layers  or  structures,  are 
not  only  divided,  but  the  inner  ones  particularly  seem  to  be  curved  inwards  on 
themselves,  so  that  the  cut  edge  of  one  half  or  side  is  not  applied  to  its  fellow 
in  the  usual  way  of  two  surfaces,  but  by  curving  inward  meets  its  opponent  on 
every  point  of  a  circle,  and  in  this  way  forms  a  barrier  inside  that  of  the  external 
coat,  which  is  tied  around  it  by  the  ligature ;  so  that  in  fact  when  a  small  liga- 
ture is  firmly  tied,  its  direct  pressure  is  not  applied  to  the  inner  coats,  which 


374 


Da  vies,  Silver  Wire  Ligatures. 


[April 


have  been  divided  and  curled  away  from  it,  but  to  the  two  layers  of  the  outer 
coat  which  are  in  consequence  of  that  pressure  made  to  ulcerate  or  slough. 

"  The  cut  edges  of  the  four  inner  layers  being  from  this  provision  of  nature 
perfectly  free,  are  capable  of  taking  on  the  process  of  inflammation  which  stops 
at  the  adhesive  stage.  This  they  do  by  the  effusion  of  lymph  or  fibrin  both 
within  and  without,  to  a  greater  or  less  extent  as  the  case  may  require." 

T  have  frequently  tested  the  truthfulness  of  this  description,  by  examin- 
ing arteries,  after  they  have  been  tied  with  silk,  both  upon  dead  and  living 
subjects,  and  have  had  occasionally  opportunities  of  doing  so  after  a  liga- 
tion has  been  made  by  a  silver  wire :  the  result  of  my  observations  has 
been,  that  their  effects  were  identical,  and  that  they  corresponded  with 
Guthrie's  account. 

On  October  24,  1862,  a  patient  of  Dr.  Porter's,  upon  whom  I  had  tied 
the  arteries  with  silver  wire  after  an  amputation  of  the  leg  four  days  pre- 
viously, died.  Within  the  posterior  tibial  artery,  the  only  one  I  was  enabled 
to  examine,  I  found  that  for  half  an  inch  above  the  site  of  ligation  the 
blood  was  firmly  coagulated,  the  internal  and  middle  coats  of  the  artery 
were  uniformly  cut  through,  and  that  there  was  as  completely  organized  a 
structure  (as  could  be  expected  in  so  short  a  time)  between  and  around 
them. 

Allowing,  then,  that  a  ligature  of  silver  wire  acts  as  well  as  a  silken  one 
does,  is  any  advantage  to  be  ascribed  to  it  ?  or  is  it  a  mere  change  of  the 
material  constituting  the  ligature  ? 

I  believe  that  there  is  a  material  advantage  in  a  silver  wire  ligature  over 
the  usual  silken  one. 

And  that  this  advantage  consists  in  the  capability  of  silver  wire  for 
remaining  in  tissues  nearly  if  not  quite  innocuous. 

Thus,  while  the  artery  is  undergoing  its  process  of  obliteration,  a  silver 
wire  ligature  does  not  of  itself  constitute  a  focus  for  purulent  secretion, 
permeating  tissues  which  we  are  endeavouring  to  unite  by  immediate  adhe- 
sion, and  these  tissues  temporarily  weakened  by  their  supply  of  blood  being 
diminished. 

Of  the  harmlessness  resulting  from  silver  wire  remaining  in  living  tissue, 
I  have  been  for  some  time  struck. 

In  a  girl  upon  whom  I  operated  for  staphyloraphy,  nearly  four  years 
ago,  a  silver  wire  still  remains ;  it  is  the  lowest  one  of  three  sutures  that  I 
inserted ;  at  the  time  of  the  removal  of  the  other  two,  not  being  satisfied 
with  the  union  of  the  soft  palate,  I  permitted  it  to  remain,  and  was  not 
allowed  afterwards  to  remove  it  as  it  occasioned  no  inconvenience. 

Just  two  years  ago,  I  had  operated  on  a  case  of  vesico -vaginal  fistula, 
by  simply  uniting  the  revivified  edges  of  the  fistule  with  silver  wire  sutures. 
On  the  tenth  day  of  their  insertion  I  intended  to  remove  them,  but  from 
an  accident  was  unable  to  do  so  for  three  months,  when  I  found  the  case 
perfectly  cured. 


1863.] 


Da  vies,  Silver  Wire  Ligatures. 


3T5 


In  the  London  Medical  Times  (I  think  for  July,  1859)  I  have  recorded 
and  illustrated  by  a  woodcut  of  the  parts  implicated,  a  case  in  which  I  had 
attempted  a  radical  cure  of  hernia  on  a  woman.  T  had  operated  by  the 
method  described  in  Druifs  Surgery  as  one  suggested  by  me. 

The  patient  on  the  eighth  day  after  operation  died  from  the  consequences 
of  intussusception  of  the  bowel,  on  the  opposite  side  to  the  one  I  had  ope- 
rated upon.  The  parts  implicated  in  the  operative  procedure  demonstrated 
well  the  perfect  immunity  from  inflammatory  process  with  which  silver  wire 
had  perforated  peritoneum  even  in  three  places. 

In  a  case  which  I  published  in  the  Lancet,  J uly,  last  year,  and  which  is 
recopied  in  Braithwaite' 's  Retrospect  of  Med.  and  Surg.,  I  say  : — 

"A  patient,  aged  17  years,  was  admitted  into  the  Birmingham  Work- 
house Infirmary  on  the  10th  of  December,  1858.  He  was  the  subject  of 
varicocele  on  the  left  side,  which  had  existed  for  three  years,  and  to  so  great 
an  extent  as  to  prevent  him  from  following  his  employment. 

"  Being  desirous  of  radically  curing  him,  I  adopted  the  method  of  M. 
Ricord,  which  I  had  seen  him  perform  with  success,  but  instead  of  using 
the  silken  ligature  which  he  used,  I  tried  to  do  the  same  thing  with  silver 
wire,  namely,  between  the  vas  deferens  and  the  veins  I  passed,  by  means  of 
a  needle,  a  double  wire  ;  and  by  the  same  apertures  in  the  opposite  direc- 
tion, anterior  to  all  the  veins,  another  wire.  By  engaging  one  free  end 
through  the  loop  of  the  other  one  on  both  sides,  the  veins  were,  by  traction 
on  the  wire,  compressed.  This  traction  was  kept  up  continuously  by  means 
of  an  elastic  watch-spring  bent  in  the  shape  of  a  horseshoe. 

"In  ten  days'  time,  thinking  the  varicocele  cured,  and  wishing  to  remove 
the  wires,  I  tried  to  do  so,  and  found  I  could  not,  though  it  was  easy 
enough  with  the  silken  ligatures.  I  therefore  cut  off  the  wires  as  short  as 
I  could,  trusting  to  the  innocuity  of  silver  wires  to  cause  no  harm.  In 
another  week  the  punctures  were  well  healed,  and  he  was  discharged,  the 
varicocele  then  appearing  perfectly  cured.  Seeing  him  again  in  about  a 
year's  time,  upon  examination  I  found  that  all  things  remained  as  when 
he  left ;  and  he  stated  that  he  had  resumed  his  work  immediately  upon 
leaving.  He  himself  was  totally  unaware  of  there  being  any  wires  in  his 
scrotum." 

But  as  a  wire  of  silver  is  a  foreign  body  to  the  tissues,  it  should  there- 
fore be  treated  as  such,  removed  in  general,  and  left  alone  when  its  removal 
is  undesirable  in  any  particular  case. 

In  conclusion  I  would  say,  that  when  left  temporarily  in  the  soft  parts — 
as  a  ligature  or  suture — I  have  observed  that  iUcreates  a  surprisingly 
small  amount  of  irritation  to  them,  and  am  very  glad  that  the  same  fact 
has  been  similarly  noticed  and  spoken  of  to  me  by  those  who  have  had  the 
fullest  opportunities  of  noticing  the  effects  produced  by  silver  wire  ligatures 
in  cases  of  amputation  under  their  care. 


316       Thomas,  Ovarian  Dropsy  treated  by  Iodine  Injections.  [April 


Art.  IX.  —  Ovarian  Dropsy  treated  by  Iodine  Injections.    By  D.  G. 
Thomas,  M.  D.,  of  Utica,  N.  Y. 

Physicians  who  have  had  the  care  of  many  cases  of  ovarian  dropsy, 
have  no  need  of  any  statements  from  me  asserting  its  fatal  character,  and 
our  inability  to  arrest  its  progress  by  medical  treatment.  It  is  true  that 
so  long  as  the  enlargement  does  not  interfere  with  the  general  health  and 
comfort  of  the  patient,  and  so  long  as  its  discomforts  can  be  borne  without 
too  much  suffering,  it  is  best  to  leave  the  disease  without  interference  from 
art.  But  in  almost  all  of  these  cases  a  time  does  come  when  surgical  aid 
can  alone  offer  a  chance  for  relief.  Paracentesis  is  the  simplest  mode  of 
surgical  treatment,  but  the  relief  obtained  by  it  is  almost  invariably  only 
palliative.  It  is  true  that  occasionally  cases  have  been  reported  cured  by 
this  operation  ;  some  change  having  been  produced  in  the  secreting  surface 
of  the  sac,  sufficient  to  arrest  the  further  progress  of  the  disease.  The  first 
operation  is  not  devoid  of  danger,  but  this  is  much  lessened  in  the  succeed- 
ing ones  which  may  be  required.  Prom  a  report  published  in  the  London 
Medical  Gazette  in  1836,  every  5th  first  operation  was  fatal.  This  is  a 
much  greater  ratio  of  mortality  than  is  shown  to  occur  by  more  recent  sta- 
tistics. From  this  report  it  would  appear  that  after  simply  tapping  and 
evacuating  the  cyst,  the  average  duration  of  life  is  eighteen  months.  Prom 
recent  statistics  the  ratio  of  mortality  from  first  operations  is  shown  to  be 
about  one  in  12  or  14. 

The  formidable  and  dangerous  operation  of  extirpation  will  seldom  be 
had  recourse  to,  if  a  safer  and  more  promising  operation  is  within  the 
surgeon's  reach.  Por  the  last  few  years,  the  profession  has  been  looking 
for  safer  means  in  the  use  of  injections,  applied  on  the  same  principles  of 
action  as  they  have  been  in  cases  of  hydrocele. 

Yelpeau,  in  1843,  was  the  first  to  suggest  the  use  of  iodine  injections  in 
these  cases.  M.  Boinet  afterwards  carried  out  the  practice  systematically 
in  France,  and  brought  it  before  the  profession  as  a  recognized  operation. 
Yelpeau  furnished  the  first  reliable  report  of  cases  thus  treated,  at  a  discus- 
sion before  the  French  Academy  of  Medicine,  on  the  surgical  management 
of  ovarian  dropsy.  From  this  report  of  110  cases  injected  64  were  cured, 
36  relieved,  and  10  died.  The  number  of  deaths  is"  one  in  every  11  cases 
injected,  about  the  same  ratio  of  mortality  that  occurs  from  tapping.  Pro- 
fessor Simpson  estimates  the  number  of  cures  of  those  injected  at  about 
one-third,  but  in  those  cases  where  a  permanent  cure  has  not  been  obtained, 
the  refilling  of  the  sac  has  been  delayed,  and  the  general  health  greatly 
improved.  The  probability  is  that  had  Yelpeau  waited  a  longer  time  after 
his  operations  before  reporting  them,  that  some  of  the  cases  he  reported 
cured  would  have  been  proved  to  be  only  in  a  measure  relieved.   Dr.  Allison, 


1863.]    Thomas,  Ovarian  Dropsy  treated  by  Iodine  Injections.  371 

of  Indiana,  in  1846,  used  an  injection  of  tincture  of  iodine  in  an  ovarian 
cyst  which  he  had  several  times  evacuated,  and  succeeded  in  obliterating 
the  sac ;  and  this  is  the  only  case  which  I  can  find  that  has  been  reported 
in  the  United  States. 

Professor  Simpson  first  applied  the  remedy  in  1851.  He  has  used  it  in 
between  forty  and  fifty  cases,  and  only  one  death  has  occurred  as  the  result 
of  the  injection.  In  this  case  the  sac  was  very  large,  and  injected  with 
tinct.  of  iodine  immediately  after  the  first  evacuation.  Symptoms  of  col- 
lapse came  on,  and  the  case  terminated  fatally  in  six  or  eight  fyours.  From 
this  report  of  Professor  Simpson  the  operation  does  not  appear  to  be 
attended  with  a  great  degree  of  danger.  He  reports  the  three  following 
results  to  be  obtained  :  About  one-third  are  perfectly  cured.  A  part  of  the 
remainder  are  greatly  relieved,  and  life  prolonged ;  while  in  a  few  cases  but 
little  effect  is  produced.  Multilocular  cysts  that  are  small  cannot  be  suc- 
cessfully injected ;  while  an  exalted  and  feverish  state  of  the  system,  or 
symptoms  of  inflammation  of  the  sac,  would  contra-indicate  any  operation 
until  such  conditions  had  been  corrected.  Having  during  the  last  year 
applied  the  remedy  successfully,  I  propose  to  report  briefly  in  detail  the 
several  steps  in  each  operation,  and  the  effects  of  each  injection. 

1861.  Dec.  30.  I  was  called  to  visit  Mrs.  J  ,  aged  65,  then  a  resi- 
dent of  Albany,  but  at  the  time  visiting  a  daughter  in  the  city  of  Utica. 
She  had  lost  much  flesh,  had  a  very  fetid  breath,  slightly  furred  tongue,  a 
tolerably  good  appetite ;  and  a  haggard  and  anxious  expression  of  counte- 
nance. The  abdomen  was  greatly  distended.  After  a  careful  examination 
of  her  case  and  its  history,  I  concluded  it  was  a  case  of  ovarian  dropsy, 
and  suggested  to  her  and  her  friends  the  course  which  was  afterwards 
adopted,  as  the  one  most  likely  to  lead  to  a  successful  issue.  Dr.  Coventry 
saw  her  with  me  the  next  day,  and  she  was  put  under  treatment  for  the 
purpose  of  correcting  in  some  measure  her  general  health,  although  the 
absorption  of  the  fluid  was  not  lost  sight  of,  in  the  remedies  selected.  The 
secretion  or  the  kidneys  had  for  a  long  time  been  small  in  quantity,  and 
was  not  particularly  increased  by  the  treatment.  As  no  change  except  a 
slight  amelioration  of  the  more  urgent  symptoms  had  been  produced,  on  the 
15th  of  January,  1862,  assisted  by  Dr.  Coventry,  the  trocar  was  used,  and 
nine  quarts  of  a  ropy  fluid  were  drawn  off,  which  was  quite  transparent  until 
near  the  last,  when  it  became  of  a  slight  coffee  groundcolor,  with  flocculi  in 
small  quantities  floating  in  the  fluid.  But  slight  disturbance  followed  the 
operation,  and  after  four  days  she  was  put  on  the  internal  use  of  Lugoll's 
solution  of  iodine.  She  improved  in  health  and  spirits,  and  February  3d, 
returned  to  Albany.  The  sac  was  evidently  refilling  when  she  left.  She 
came  to  Utica  again,  and  on  the  10th  of  March  the  operation  was  repeated, 
and  six  quarts  withdrawn.  The  injection  of  the  sac  was  delayed  for  this 
time,  to  allow  the  system  to  become  more  accustomed  to  the  changes  it 


3T8       Thomas,  Ovarian  Dropsy  treated  by  Iodine  Injections.  [April 

might  induce,  and  thus  render  the  operation  less  hazardous  t  we  were  tread- 
ing on  untried  ground  to  us,  and  were  anxious  to  give  our  patient  the 
benefit  of  great  care  and  prudence,  also  believing  it  better  to  operate  before 
the  sac  was  so  much  distended.  Her  general  health  has  remained  about 
the  same,  but  perhaps  . slightly  improved.  She  returned  from  Albany  the 
second  day  of  April,  and  on  the  fourth,  assisted  by  Dr.  Coventry,  at  half- 
past  twelve,  I  drew  off  three  quarts  of  water,  ropy,  but  transparent,  and  free 
from  any  flocculi  or  coffee  ground  appearance.  Injected  four  ounces  of 
fluid  at  blood  heat,  containing  16  grs.  of  iodine,  and  60  of  the  iodide  of 
potassa,  and  after  pressing  the  sides  of  the  sac  so  as  to  bring  every  part  of 
it  in  contact  with  the  fluid,  drew  it  off,  by  using  the  glass  syringe  to  take 
it  up,  at  the  same  time  the  walls  of  the  abdomen  were  firmly  supported 
with  the  bandage  and  the  assistants.  The  contact  of  the  fluid  with  the 
inside  of  the  sac  produced  severe  pain ;  she  suddenly  became  faint,  and  was 
covered  with  a  cold  perspiration.  Gave  her  hot  camphor  sling,  applied  a 
plaster  to  the  puncture,  put  her  in  bed,  and  supported  the  abdomen  with  a 
firm  bandage.  Gave  her  a  pill  of  opii  1  gr.,  calomel  1  gr.,  camphor  2  grs. 
In  the  course  of  half  an  hour  the  colour  began  to  return  to  her  face,  and 
reaction  soon  became  established.  The  pain  and  uneasiness  continued,  and 
at  3  P.  M.  the  pill  was  repeated.  8  P.  M.  The  pain  in  the  bowels  is  re- 
lieved. The  pulse  is  frequent  with  considerable  force.  There  is  uneasi- 
ness in  the  abdomen  and  pain  in  moving  about  in  the  bed,  and  tenderness 
of  the  whole  body.  Pill  to  be  repeated  every  four  or  six  hours,  as  may 
be  required. 

6th.  9  A.  M.  Has  had  a  comfortable  night,  and  slept  several  hours. 
The  pulse  it  less  frequent,  but  has  more  force.  The  same  tenderness  of 
the  bowels  and  body  continues,  with  a  decided  increase  in  the  fulness  of  the 
abdomen.  Simple  farinaceous  diet.  From  this  day  she  continued  to  im- 
prove steadily,  until  the  17th,  two  weeks  after  the  injection,  when  she  re- 
turned to  Albany  feeling  quite  well,  although  there  was  some  evidence  of 
refilling  of  the  sac. 

May  1.  Came  back  from  Albany  yesterday.  Has  been  quite  well,  but 
has  felt  more  debilitated  since  the  last  operation.  There  has  been  some 
increase  of  the  effusion,  but  it  has  not  been  as  rapid  as  before.  The  walls 
of  the  sac  seem  much  more  thin  and  soft.  Deemed  it  prudent  to  wait  a 
few  days  and  watch  the  progress  of  the  case. 

12th.  At  11.30  drew  off  three  quarts  and  one  pint  of  thick  ropy  fluid, 
of  a  light  green  colour.  Injected  48  grs.  of  iodine,  180  grs.  of  iodide  of 
potash,  in  8  ounces  of  water  at  blood  heat.  She  had  taken  30  drops  of 
McMunn's  elixir  opii,  forty-five  minutes  before  the  operation,  to  diminish 
the  force  of  the  shock.  She  suffered  much  less  from  the  injection  than 
before,  although  its  strength  had  been  greatly  increased,  and  the  quantity, 
eight  ounces  instead  of  four.   It  was  allowed  to  remain  about  five  minutes, 


1863.  J    Thomas,  Ovarian  Dropsy  treated  by  Iodine  Injections.  319 

and  was  then  drawn  off,  as  in  the  first  operation.  At  half-past  two,  three 
.  hours  after  the  injection,  she  had  a  chill,  which  lasted  twenty  minutes. 
She  took  two  of  the  camphor  pills  and  some  warm  drinks.  7  P.  M.  Face 
is  flushed,  skin  hot  and  dry,  pulse  frequent  and  hard,  with  great  thirst. 
She  has  passed  a  large  quantity  of  urine,  which  continued  free  through  the 
night. 

13th.  She  has  had  a  comfortable  night,  and  continued  quite  well  through 
the  day.    Took  a  pill  at  11,  4,  and  10. 

ltth.  Slept  well  until  half-past  five  in  the  morning,  when  she  was  seized 
with  severe  pain  in  the  bowels.  Saw  her  about  T  A.  M.  Severe  pain  in 
the  abdomen,  which  was  greatly  distended,  great  difficulty  in  moving, 
although  there  was  but  little  tenderness  on  pressure;  whole  body  was 
covered  with  a  profuse  perspiration ;  pulse  frequent  and  hard ;  hands  looked 
as  if  partially  par  boiled,  of  a  leaden  hue,  with  the  same  appearance  of  col- 
lapse printed  on  the  face.  She  had  taken  two  of  the  camphor  pills  before 
my  arrival,  ordered  free  use  of  camphor  julep,  gave  a  pill  every  hour,  and 
applied  strong  mustard  over  the  abdomen,  and  bottles  of  hot  water  about 
the  lower  extremities.  At  half-past  eleven  she  seemed  much  improved. 
Less  tumefaction  of  the  bowels,  pulse  less  frequent,  surface  more  dry,  with 
an  increased  activity  and  tone  in  the  capillary  vessels  ;  ordered  one  pill 
every  two  hours,  and  an  enema.  3  P.  M.  Bowels  well  moved,  has  had  a 
fine  sleep  and  feels  better.  At  nine  in  the  evening  found  a  gradual  im- 
provement, and  directed  a  pill  every  four  hours. 

15th.  9  A.  M.  Has  had  a  comfortable  night.  Feels  better.  Pulse 
more  slow  and  full,  distension  of  abdomen  about  the  same  as  last  evening, 
tongue  still  furred.    Pill  every  four  hours. 

lQth.  Comfortable  night.  Bowels  opened  with  congress  water.  Tongue 
has  improved.  Complains  of  a  feeling  of  exhaustion.  There  is  slight 
tenderness  of  abdomen  on  pressure,  the  fulness  about  the  same.  Pill  every 
three  or  four  hours  as  may  be  necessary  to  allay  pain. 

1*1  th.  Continues  to  improve.  The  bowels  have  a  doughy  feel,  but  there 
is  no  tenderness  on  pressure.  They  have  been  freely  open  from  the  calomel 
in  pills,  which  were  omitted,  and  small  doses  of  opium  given  to  control  the 
bowels. 

23d.  Has  continued  to  improve,  eats  and  sleeps  well,  and  has  no  further 
need  of  anodynes. 

28th.  Gaining  constantly,  but  complains  of  debility.  Gave  proto- 
iodide  ferri,  six  grains  each  day. 

June  10th.  She  returned  to  Albany.  Since  the  last  operation  the  secre- 
tion of  the  kidneys  has  been  natural,  and  although  there  is  some  fulness  of 
the  bowels,  I  am  inclined  to  think  it  the  product  of  the  inflammation  which 
followed  the  injection. 

Saw  her  again  in  October.  She  called  herself  well ;  could  walk  with  ease 
three  or  four  miles.    Had  gained  in  flesh ;  the  size  of  the  bowels  was  natural, 


380  Wales,  Gunshot  Wound  of  Chest  and  Abdomen.  [April 

and  the  walls  or  outline  of  the  collapsed  sac  could  be  easily  traced  through 
the  abdominal  parietes. 

I  have  now  another  case  under  treatment,  where  no  efforts  have  been 
made  to  exclude  the  air  from  entering  the  sac,  and  in  which  in  two  in- 
stances, half  of  the  injected  fluid  could  not  be  withdrawn;  but  no  injurious 
effects  were  produced  by  its  being  retained  in  the  system. 


Art.  X.  —  Gunshot  Wound  of  Chest  and  Abdomen.    By  Philip  S. 
Wales,  M.  D.,  Surgeon  U.  S.  N. 

Jacob  Myers,  ordinary  seaman,  aged  23,  admitted  March  *Jth,  1863, 
with  a  gunshot  wound  of  the  chest  and  abdomen.  He  was  pale,  with  an 
anxious  expression  of  countenance  ;  the  least  movement  caused  excruciating 
pain  across  the  epigastrium  and  loins.  Dark  blood  issued  from  the  pos- 
terior wound,  which  was  between  the  transverse  processes  of  the  last  dorsal 
and  first  lumbar  vertebras,  immediately  below  the  neck  of  the  twelfth  rib. 
Suffers  from  thirst,  and  the  injection  of  the  smallest  amount  of  fluid  causes 
vomiting  and  violent  retching,  the  patient  flexing  strongly  both  thighs 
against  his  abdomen.  During  these  efforts  blood,  almost  black,  spirts  out 
at  the  lower  opening,  and  bright  arterial  blood  at  the  upper  one,  which 
was  exactly  over  the  right  rib,  an  inch  or  two  from  its  junction  with  the 
costal  cartilage.  The  pulse  was  feeble,  and  the  patient  very  restless,  tossing 
about  incessantly.  With  compressors  and  adhesive  straps  the  bleeding 
was  stopped.  Soon  after  his  admission  he  passed  bloody  urine,  which 
coagulated  in  the  chamber.  Stimulants  were  had  recourse  to  in  exceeding 
small  quantities  at  a  time,  under  which  treatment  the  pulse  rose  a  little. 
Towards  noon  he  became  more  restless,  and  complained  that  the  adhesive 
straps  oppressed  his  breathing  ;  they  were  removed,  but  without  affording 
the  relief  the  patient  vainly  hoped  would  follow;  the  stomach  was  distended 
and  made  a  perceptible  projection  in  upper  region  of  the  abdomen.  The 
eyes  became  glassy,  the  pulse  vanished  from  the  wrists  and  ankles,  the 
respiration  unequal  and  frequent,  the  inspiration  was  taken  with  a  gasp, 
and  the  expiration  became  twice  as  long  as  the  former,  and  seemed  to  be 
effected  in  two  expulsive  acts  ;  the  first  sound  of  the  heart  was  normal  and 
strong,  the  second  could  not  be  heard  at  all.  Later  the  pulsation  of  the 
larger  arteries  could  not  be  felt ;  the  first  sound  of  the  heart  ceased,  yet 
the  patient  gasped,  and  once  raised  his  head  from  the  pillow ;  with  every 
gasp  the  corners  of  the  mouth  were  depressed,  the  central  portion  of  the 


1863.]       Wales,  Gunshot  Wound  of  Chest  and  Abdomen.  38] 

lower  lip  rose  up  and  met  its  fellow.  The  head  was  strongly  drawn  to  the 
left  shoulder,  and  with  one  forcible  expiration  the  patient  expired. 

The  pectoral  and  abdominal  muscles  became  first  affected  with  post-mor- 
tem rigidity,  then  the  muscles  of  the  limbs,  from  which  it  gradually  spread 
to  the  balance  of  the  muscles  of  the  head  and  trunk. 

Autopsy  eighteen  hours  after  death. — The  musket  ball  comminuted  the 
eighth  rib  on  left  side,  one  or  two  inches  from  its  attachment  to  the  costal 
cartilage,  passed  through  the  diaphragm  on  the  left  side,  three  inches  from 
its  lower  margin,  making  an  aperture  about  1 J  inches  in  diameter,  wounding 
the  upper  part  of  the  spleen,  from  which  a  copious  hemorrhage  had  taken 
place  into  the  pleural  sac — the  tissue  of  that  organ  being  broken  down  into 
a  black  mass — then  passed  through  the  upper  part  of  the  left  kidney,  from 
which  the  blood  had  escaped  to  the  extent  of  half  a  pint,  but  confined  by 
the  cellular  capsule  of  that  organ,  the  tissue  of  which  was  also  broken  down 
into  a  friable  dark-coloured  matter.  The  ball  afterwards  struck  the  upper 
and  left  extremity  of  the  stomach,  making  a  similar  hole  as  in  the  dia- 
phragm, and  passed  out  of  this  viscus  by  an  equally  large  opening  about 
midway  of  its  greater  curve,  and  finally  emerged  below  the  diaphragm  between 
the  transverse  processes  of  the  twelfth  dorsal  and  first  lumbar,  fracturing 
the  neck  of  the  left  twelfth  rib.  About  a  quart  of  black  blood  was  found 
in  the  left  pleural  cavity,  and  a  mass  of  the  omentum  had  been  forced 
through  the  diaphragmatic  opening  and  contracted  adhesion  to  the  external 
wound.  A  small  quantity  of  dark  coagula  was  found  in  the  abdomen,  and 
also  arountl  the  opening  in  the  stomach.  The  omentum  was  adherent  on 
the  left  side  of  the  abdomen,  but  not  at  the  posterior  orifice,  being  sepa- 
rated from  it  by  coagula.  The  liver  was  healthy,  and  the  gall-bladder  dis- 
tended with  bile.  The  pericardium  contained  about  two  ounces  of  serum. 
The  left  lung  was  congested,  and  its  lower  margin  hepatized,  but  not 
wounded;  the  posterior  half  of  right  lung  congested  also,  the  balance 
healthy.    Some  blood  in  the  bladder,  other  organs  healthy. 

The  diagnosis  made  in  this  case  exactly  accorded  with  the  post-mortem 
i  lesions.  The  dark,  or  almost  black  blood,  issuing  from  the  wound  on  the 
posterior  portion  of  left  side,  and  its  position,  lead  to  the  supposition  of  a 
wound  of  the  spleen.  The  urine  being  bloody,  pointed  to  the  kidney  as 
participating  in  the  injury.  Singular  enough,  notwithstanding  the  two 
large  orifices  in  the  stomach,  not  a  drop  of  blood  was  vomited,  though  the 
patient  expelled  the  contents  of  the  stomach  two  or  three  times  after  his 
admission  into  the  hospital,  and  from  this  fact  it  was  surmised  that  the 
stomach  might  have  escaped. 

In  this  case  the  omentum  did  not  project  from  the  external  wound, 
although  adherent  to  the  pleura  costalis  around  it ;  yet  I  have  witnessed 
such  protrusion  in  several  examples  when  the  wound  was  much  higher  up, 
even  at  the  sixth  rib.    A  man  presented  this  condition  of  things  about  three 


382  Turner,  Treatment  of  Varicose  Veins  with  Antimonii,  etc.  [April 

months  ago  in  this  hospital.  Surgeon  Sharp  informed  me  that  he  saw  a 
case  where  the  projecting  omentum  was  taken  for  the  lung  tissue. 

My  patient  survived  the  wound  ten  hours ;  and  yet,  in  this  short  time, 
extensive  adhesion  had  taken  place  between  the  serous  layers  of  the  peri- 
toneum in  the  abdomen  and  this  last  membrane  to  the  parietes  of  the  chest. 

All  the  cases  of  wounds  of  the  spleen  or  kidney  that  have  come  under 
my  notice  have  proved  fatal  in  periods  varying  from  ten  hours  to  two  days. 


Art.  XI. — On  the  Use  of  Antimonii  et  Potassae  Tartras  and  Oleum 
Tiglii  in  establishing  Adhesive  Inflammation  over  Varicose  Veins. 
By  S.  P.  Turner,  M.  D.,  one  of  the  Physicians  to  the  Howard  Hospi- 
tal and  Infirmary  for  Incurables. 

Having  upon  several  different  occasions  been  forced  to  resort  to  the 
obliteration  of  varicose  veins  of  the  lower  extremities  by  means  of  issues 
established  over  their  course,  inducing  a  deposition  of  fibrin  within  the 
areolar  tissue  surrounding  them,  and  not  meeting  the  desired  satisfaction 
from  the  use  of  potassa  fusa  or  Vienna  paste,  because  of  the  great  tend- 
ency to  considerable  inflammation  of  the  skin  about  the  issue,  and  the 
impossibility  of  limiting  the  action  to  the  exact  location  desired,  and  the 
usual  very  tedious  process  of  cicatrization,  I  have  finally  resorted  to  a 
substitute,  which  appears  to  have  answered  the  desired  indication  in  the 
instances  where  it  has  been  employed,  without  these  objectionable  results  : 
it  is  the  antimonii  et  potassae  tartras  mixed  with  oleum  tiglii  to  form  a 
paste  of  the  desired  consistence. 

From  the  following  cases  its  mode  of  application  can  be  seen,  with  a 
report  of  the  state  in  which  the  patient  was  left  when  last  under  observation. 

Case  1.  Robt.  Mc  ,  aet.  38,  labourer.    Some  years  since  he  received 

a  severe  blow  upon  the  inner  surface  of  the  tibia,  which  was  followed  by 
enlargement  of  the  neighbouring  veins,  gradually  extending  along  the 
saphena  three  or  four  inches  above  the  knee.  Since  that  time  he  has  suf- 
fered much  each  winter  from  ulceration  at  or  near  the  internal  malleolus, 
which  usually  disappeared  after  rest  with  the  limb  elevated,  and  the  use  of 
some  stimulating  application,  until  more  recently  the  size  of  the  veins  had 
increased  to  such  an  extent  as  to  render  him  almost  unfit  to  follow  his 
vocation,  from  the  pain  and  sense  of  weight  consequent  upon  the  distension 
of  the  vessels  at  fault. 

When  he  presented  himself  for  treatment,  there  was  a  few  inches  above 
the  internal  malleolus  a  large  irregular  point  of  ulceration  with  elevated 
and  indurated  margins  of  a  purplish  colour  from  long-continued  congestion. 
The  internal  saphena  vein,  beginning  at  the  dorsum  of  the  foot  and  extend- 
ing to  a  point  three  inches  above  the  internal  condyle  of  the  femur,  was 


1863.]  Turner,  Treatment  of  Yaricose  Veins  with  Antimonii,  etc.  383 

largely  dilated  and  tortuous,  from  elongation  in  some  places  appearing  as 
if  ready  to  burst  from  attenuation  of  its  coverings.  The  pain  was  very 
severe,  especially  at  night,  and  he  seemed  somewhat  exhausted  for  want  of 
proper  rest. 

June  5.  A  cathartic  having  been  given  the  day  previous,  with  directions 
that  the  bowels  be  kept  regular,  the  patient  was  placed  in  bed  with  the 
affected  limb  well  elevated  and  supported  upon  a  pillow. 

A  strip  of  ordinary  emplast.  cantharidis,  about  twelve  inches  in  length 
by  one-half  in  breadth,  was  subdivided  into  some  fifteen  or  twenty  pieces ; 
then  over  each  projecting  point  of  the  vein  was  placed  one  of  these  small 
blisters,  with  the  order  that  they  be  allowed  to  remain  until  vesication  was 
established.  Twelve  hours  afterwards  it  was  found  that  out  of  the  whole 
number  applied,  over  one-half  had  produced  the  desired  effect;  the  elevated 
cuticle  was  now  removed  by  a  pair  of  scissors,  and  to  the  denuded  surface 
thus  exposed  was  applied  the  preparation  by  means  of  a  probe. 

*lth.  The  parts  to  which  the  application  had  been  made  were  each  raised 
up  as  an  umbilicated  pustule,  such  as  is  usually  seen  about  the  seventh  day 
after  vaccination.  The  patient  complains  of  but  little  pain,  and  was  directed 
to  use  warm  water  dressings. 

8th.  Passed  a  quiet  night,  with  no  uneasiness;  the  vesicles  had  ruptured 
and  permitted  the  escape  of  the  contained  extravasated  blood,  showing  at 
the  bottom  of  the  ulcer  a  slough  which  had  begun  to  separate  from  the 
adjacent  parts;  water  dressings  continued. 

9th.  The  sloughs  occupying  the  centre  of  each  ulcer  had  entirely  sepa- 
rated and  been  removed,  exposing  a  well-defined  depression  with  perpen- 
dicular edges ;  indeed,  looking  as  if  they  had  been  cut  out  by  means  of  a 
punch.  Granulations  were  already  springing  up  from  the  bottom  and  sides 
of  each  ulcer,  so  that  in  a  few  days  cicatrization  was  complete. 

Sept.  18.  The  site  of  each  ulcer  is  distinctly  marked  by  a  firm  cicatrix, 
whilst  the  size  of  the  vein  beneath  has  diminished  in  the  same  proportion. 
The  original  ulceration  over  the  malleolus  has  completely  closed,  and  has 
showed  no  tendency  since  to  return.  He  was  now  advised  to  use  a  laced 
stocking,  which  could  be  worn  with  comfort,  when  previously  it  had  given 
considerable  pain. 

Since  this  time  he  has  been  seen  once,  and  has  no  appearance  as  if  a 
return  of  the  varicose  state  was  to  be  apprehended. 

Case  2.  Jane  R.,  set.  43.  Has  not  been  able  to  leave  the  house  for 
some  months  past  from  a  varicose  condition  of  the  internal  saphena  vein 
and  its  ramifications,  which  she  referred  to  repeated  pregnancies  and  pro- 
longed standing  upon  the  feet.  The  circumference  of  the  left  limb  when 
the  erect  posture  is  assumed,  measures  nearly  one-third  more  than  that  of 
the  sound  one;  while  over  the  inner  tibial  region  exists  a  large  irregular 
ulcer,  discharging  a  most  fetid  pus.  She  was  placed  in  bed  with  the  limb 
well  elevated,  with  directions  that  the  bowels  be  kept  regular. 

Sept.  20.  To  a  number  of  places  where  the  vein  seems  very  prominent 
an  ethereal  solution  of  cantharides  was  touched  by  means  of  a  camel-hair 
pencil.  Some  hours  afterwards  the  raised  cuticle  was  removed,  and  to  the 
centre  of  each  denuded  surface  the  antimonii  et  potass,  tart,  cum  olei  tiglii 
was  applied. 

21s£.  The  parts  to  which  the  application  had  been  made  presented  the 
peculiar  umbilicated  vesicular  appearance  of  the  former  case,  which,  after 


384  Turner,  Treatment  of  Varicose  Veins  with  Antimonii,  etc.  [April 

dischargiag  their  contents,  exposed  the  slough,  which  was  assisted  in  be- 
coming detached  by  water  dressings. 

23d  The  sloughs  have  all  become  loosened  and  removed,  leaving  a  well 
denned  ulcer  of  the  same  size,  and  of  from  one-fourth  to  five-eighths  of  an 
inch  in  depth,  surrounded  by  a  small  circle  of  inflammation.  Granulation 
was  now  allowed  to  proceed,  and  by  the  28th  cicatrization  was  complete. 

Oct.  20.  The  primary  ulcer  over  the  tibia  has  yielded  to  the  occasional 
stimulating  action  of  argenti  nitras,  while  the  size  of  the  vein  has  consider- 
ably diminished,  and  with  it  that  of  the  limb.  She  is  able  to  wear  an 
elastic  stocking,  aud  feels  but  little  of  the  pain  and  uneasiness  formerly 
experienced  when  the  limb  was  permitted  to  occupy  a  dependent  position. 

Case  3.  Mary  R.,  domestic,  get.  50.  Six  years  ago  was  much  troubled 
by  constipation,  which  she  considers  the  origin  of  the  present  state,  which 
is  an  enlarged  and  tortuous  state  of  the  veins  of  the  left  limb,  beginning 
at  the  foot  and  extending  to  the  popliteal  space,  where  the  form  of  a  tumour 
is  attained  nearly  as  large  as  an  orange.  The  patient  complains  of  great 
pain  in  the  limb  with  want  of  power,  and  experiences  considerable  difficulty 
in  walking.  Several  times  she  has  been  much  annoyed  from  the  appearance 
of  ulceration  over  the  inner  surface  of  the  tibia,  which  gave  her  consider- 
able trouble  before  subdued. 

Over  the  varicose  vessels  several  eschars  were  established  by  the  applica- 
tion of  the  antimony  which  produced  the  requisite  amount  of  inflammatory 
effusion  within  the  areolar  tissue,  finally  ending  in  the  obliteration  of  the 
vessel.  The  size  of  the  limb  has  slowly  diminished,  with  a  prospect  of 
great  alleviation  if  not  a  perfect  cure. 

The  patient  is  usually  kept  in  the  recumbent  posture4,  that  the  distension 
of  the  vessel  may  be  prevented  as  much  as  possible  by  the  accumulation  of 
blood  in  it,  thus  offering  an  obstacle  to  the  compressing  agency  of  the  plas- 
tic lymph,  which  it  is  our  object  to  attain  as  much  as  possible.  The  vesi- 
cation by  the  cantharides  expedites  the  treatment  by  removing  a  layer  of 
epidermis,  which  is  usually  so  thickened  by  constant  irritation  that  it  offers 
us  slight  impediment  to  the  action  of  the  antimonii  et  potassas  tart,  made 
into  a  thick  paste  with  oleum  tiglii  and  applied  by  means  of  a  small  piece 
of  wood,  such  as  the  free  end  of  a  common  match.  This  is  followed  by  a 
vesicle,  underneath  which  is  found  the  eschar. 

The  proposed  plan  has  not  only  assisted  the  repair  of  the  lesion,  if  the 
sore  is  superficial  and  not  very  chronic,  but  in  many  instances  found  not 
only  to  palliate,  but  as  effective  as  obliteration  of  the  vein  by  the  use  of 
the  twisted  suture,  or  the  substitute  of  potassa  fusa  or  Vienna  paste,  whilst 
it  possesses  the  advantage  of  being  available  in  almost  every  instance  of 
varicose  enlargement  of  the  superficial  veins  of  the  lower  extremities. 


1863.] 


Smith,  Formula  for  a  Solution  of  Bromine. 


385 


Art.  XII. — Luxation  of  the  Head  of  the  Fibula.    By  Jos.  G.  Richard- 
son, M.  D.,  Resident  Physician  to  the  Pennsylvania  Hospital. 

The  following  example  of  this  accident  is  interesting  from  its  rarity, 
there  being  but  three  cases  of  it  on  record  ;  one  by  Sir  A.  Cooper,  another 
by  Malgaigne,  and  a  third  by  Sanson  : — 

John  Dixon,  a  schoolboy,  set.  9,  was  admitted  into  the  Pennsylvania 
Hospital,  on  the  evening  of  December  26,  with  an  injury  to  the  knee.  In 
the  absence  of  my  colleagues,  being  called  to  the  case,  I  found  the  child 
extended  upon  his  back,  with  the  left  leg  in  a  semi-flexed  posture,  and  the 
foot  slightly  everted,  apparently  suffering  considerable  pain,  and  unable  to 
completely  flex  or  extend  the  limb.  When  questioned  in  regard  to  the 
accident,  he  referred  the  uneasiness  to  the  outside  of  his  knee,  and  stated 
that  it  was  the  result  of  a  fall  of  about  five  feet  from  the  top  of  a  fence, 
and  that  he  had  struck  that  part  of  his  leg  against  something  in  his 
descent.  On  examination  a  protuberance  was  observed  on  the  outer  back 
part  of  the  leg  about  three-fourths  of  an  inch  behind  the  head  of  the  fibula. 
The  tendon  of  the  biceps  flexor,  rendered  prominent  by  spasmodic  con- 
tractions of  that  muscle  occurring  at  short  intervals,  was  distinctly  felt 
attached  to  this  prominence.  After  a  careful  scrutiny  of  the  joint  and 
surrounding  portions,  in  which  no  other  lesion  was  discoverable,  the  diag- 
nosis of  luxation  of  the  head  of  the  fibula  backwards  was  formed,  and  an 
attempt  made  to  reduce  it  by  insinuating  the  tips  of  the  fingers  beneath 
the  fibula,  so  as  to  make  some  traction  outwardly,  at  the  same  time  the 
head  of  the  bone  was  drawn  forwards  to  the  articulating  surface  on  the 
tibia.  In  this  way  the  displacement  was  overcome  with  but  little  difficulty, 
and  the  boy  enabled  to  resume  the  natural  movements  of  the  limb.  To 
guard  against  a  recurrence  of  the  luxation  from  muscular  spasm  or  other- 
wise, a  compress  was  placed  behind  the  fibula,  a  firm  bandage  applied  to 
the  leg,  and  the  patient  directed  to  remain  in  bed  with  the  limb  partly 
flexed  until  further  orders.  No  tendency  to  redislocation  being  observed, 
however,  after  a  few  days  a  cautious  resumption  of  the  usual  functions  of 
the  limb  was  permitted. 


Art.  XIII. — Formula  for  a  Solution  of  Bromine.  Proposed  by  J.  Law- 
rence Smith,  M.  D.,  Professor  of  Chemistry  in  the  Medical  Department 
of  the  University  of  Louisville. 

The  frequent  demand  for  bromine  from  the  Louisville  Chemical  Works, 
which  are  under  my  direction,  induced  me  to  inquire  for  what  purpose  it  was 
No.  XC— April  1863.  25 


386 


Smith,  Formula  for  a  Solution  of  Bromine. 


[April 


used,  and  learned  that  it  was  being  employed  as  a  therapeutic  agent,  espe- 
cially in  the  form  of  vapour  mixed  with  air  as  a  purifier  of  the  atmosphere 
of  hospitals,  where  erysipelas,  gangrene,  smallpox,  &c,  existed,  and  also 
internally  in  certain  affections  of  the  throat.  Knowing  full  well  the  incon- 
venience of  the  use  of  the  substance  in  the  form  called  for,  I  at  once  under- 
took to  compound  a  solution  which  would  meet  the  ends  required,  and  be 
more  convenient  for  any  therapeutical  use  to  which  uncombined  bromine 
might  be  applied.  From  the  slight  solubility  of  bromine,  any  attempts  to 
dissolve  it  in  water  would  give  too  dilute  and  bulky  a  solution,  the  natural 
suggestion,  therefore,  was  to  use  but  little  water  and  facilitate  its  solubility 
by  adding  bromide  of  potassium ;  at  first  the  following  proportions  were 
used:  1  troy  ounce  of  bromine,  120  grains  bromide  of  potassium,  and  1 
fluidounce  of  distilled  water  ;  the  formula  left  a  small  quantity  of  bromine 
undissolved,  and  the  solution  was  too  concentrated.  After  varying  the 
proportions  in  different  ways  I  have  settled  on  the  following  as  the  most 
convenient  formula : — 

B>. — Bromine  1  troy  ounce. 

Bromide  of  potassium  160  grains. 

Distilled  water     .    .  q.  s.  to  make  four  fluidounces  of  the  whole  mixture. 

Dissolve  the  bromide  of  potassium  in  about  two  fluidounces  of  water  in 
an  eight  ounce  bottle,  then  add  the  bromine,  agitate  gently  until  the  solu- 
tion is  complete,  then  add  water  enough  to  bring  the  whole  to  four  fluid- 
ounces. 

This  mixture  forms  a  very  dark  red  solution,  evolving  strong  fumes  of 
bromine,  and  readily  soluble  in  any  additional  quantity  of  water. 

I  have  given  this  formula  as  one  that  will,  doubtless,  recommend  itself 
to  those  of  the  medical  profession  engaged  in  using  bromine,  and  is  already 
being  used  by  the  medical  profession  of  this  place. 


1863.] 


387 


REVIEWS. 

Art.  XIV. —  The  Renewal  of  Life;  Clinical  Lectures  Illustrative  of  the 
Restorative  System  of  Medicine,  given  at  the  St.  Mary's  Hospital. 
By  Thomas  K.  Chambers,  M.  D.,  Fellow  of  the  College  of  Physicians; 
Physician  to  St.  Mary's  Hospital;  Lecturer  on  the  Practice  of  Medi- 
cine, and  Clinical  Lecturer  at  St.  Mary's  Medical  School.  London: 
John  Churchill,  New  Burlington  Street,  1862.    8vo.  pp.  430. 

Of  the  character  of  this  book  the  title  hardly  affords  an  inkling,  but  its 
pertinency  is  apparent  after  the  author's  doctrine  of  the  general  nature  of 
disease  is  apprehended.  He  begins  by  enumerating  five  principles  which, 
at  the  present  time,  influence  more  or  less  the  therapeutical  conduct  of 
those  who  undertake  the  management  of  cases  of  disease.  One  of  them  is 
allopathy,  a  name  which  physicians  properly  repudiate  as  designative  of 
legitimate  medicine,  but  which,  it  must  be  admitted,  expresses  a  line  of 
practice  pursued  to  some  extent.  The  second  is  homoeopathy,  which  the 
author  disposes  of  satisfactorily  in  a  few  words.  The  third  is  evacuation, 
the  principle  involved  in  the  measures  designed  to  eliminate  a  materies 
morbi.  The  fourth  is  counter -irritation,  a  principle  founded  on  the  idea 
of  substituting  for  a  disease  which  threatens  to  be  dangerous  or  persisting, 
an  artificial  disease  which  is  temporary  and  controllable.  The  fifth  is  stimu- 
lation, which  the  author  regards  as  a  step  forward  in  the  right  direction, 
but,  as  a  therapeutical  principle,  resting  on  a  partial  trial  only.  He  re- 
gards the  root  of  all  these  principles  as  unsound ;  all  of  them  being  based 
on  the  assumption  that  disease  is  an  entity,  a  motive  cause,  a  positive 
existence.  As  opposed  to  this  notion  of  disease,  the  author  sets  forth  his 
own  view  in  the  concluding  paragraph  of  the  first  lecture  : — 

"  Disease  is  in  all  cases  not  a  positive  existence,  but  a  negation  ;  not  a  new 
excess  of  action,  but  a  deficiency  ;  not  a  manifestation  of  life,  but  partial 
death  :  and,  therefore,  the  business  of  the  physician  is,  directly  or  indirectly, 
not  to  take  away  material,  but  to  add  ;  not  to  diminish  function,  but  to  give 
it  play  ;  not  to  lueaken  life,  but  to  renew  life.  These  are  the  principles  of 
restorative  medicine."1 

In  the  second  lecture  the  author  enters  into  a  further  exposition  of  his 
philosophy  of  disease.  Having  instituted  a  comparison  between  the  decay 
of  dead  and  of  living  bodies,  he  considers  life  as  the  principle  which  pre- 
sides over  the  changes  of  nutrition.  "Life  is  Renewal,"  "the  most 
active  renewal  of  the  body  possible,  the  highest  possible  development  of 
life  in  every  part,  is  Health."  "The  complete  cessation  of  renewal  is 
Death."    "The  partial  cessation,  or  arrest,  is  Disease." 

In  illustration  of  this  definition  of  disease,  the  degeneration  of  the  volun- 
tary muscular  fibre  after  long  disuse,  is  compared  with  the  change  which 
occurs  during  maceration  after  death,  according  to  Quain's  observations. 
So  in  other  cases  of  degeneration  there  is  a  "  diminished  life,"  or  a  "  partial 

1  The  italics  and  capitals  here  and  subsequently,  are  the  author's. 


388 


Reviews. 


[April 


death."  Cancer,  for  example,  denotes  lessened  vitality,  notwithstanding 
the  amount  of  morbid  growth,  because  it  never  puts  on  the  form  of  the 
part  it  is  planted  in,  nor  performs  its  duties."  "  Its  very  tendency  to  die 
and  to  ulcerate  is  one  of  the  chief  dangers  in  which  it  puts  your  patient." 
He  cites  the  instance  of  the  local  processes  in  a  common  cold,  because  in 
such  an  instance  the  first  impression  is  that  vital  actions  are  increased,  not 
diminished.  But  adopting  the  hypothesis  of  Yirchow,  that  the  "exudation 
or  mucous  globules,"  or  the  "pus  globules,"  found  on  an  inflamed  mucous 
surface,  are  imperfectly  developed  epithelium  cells,  this  shows  deficient 
vitality.  "  The  business  of  mucous  membranes  is  to  be  covered  with  epi- 
thelium, not  to  throw  off  mucus  ;  and  when  they  are  doing  the  latter,  they 
are  so  far  forth  in  a  state  of  diminished  life."  And  the  same  holds  true 
of  all  inflammations  ;  all  are  characterized  by  partial  death  of  the  part 
affected.  In  like  manner  blood  changes  denote  either  "a  distinctive  relapse 
into  a  less  organic  life,  or  an  arrest  of  development."  "The  poison  of 
fever,  for  example,  destroys  and  renders  useless  as  nutriment  some  con- 
stituents of  the  blood."  Anaemia  is  an  instance  of  an  arrest  of  develop- 
ment of  the  red  corpuscles. 

Carrying  the  doctrine  into  the  materia  medica,  therapeutical  measures, 
or,  as  the  author  says,  the  "tools  with  which  the  restoratist  physician  has 
to  work,"  may  be  divided  into  constrictives,  arresters,  and  destruc- 
tives.   The  restoratist  physician  deals  especially  with  constructives  : — 

"  Or,  by  the  judicious  use  of  destructives  and  arresters  of  metamorphosis,  we 
in  some  cases  make  room  for,  and  in  others  allow  time  for  the  normal  growth 
of  the  tissues,  and  thus  are  acting  up  to  our  principles  in  making  our  prime 
object  the  renewal  of  life." 

This  sketch  of  the  first  two  lectures  will  convey  a  general  idea,  if  not  a  full* 
appreciation  of  the  sense  which  the  author  attaches  to  the  terms,  "  re- 
newal of  life,"  and  "restorative  medicine."  And  this  is  all  that  we  shall 
undertake  to  do.  We  will  not  discuss  the  merits  of  the  doctrine  which 
the  author  considers  to  be  the  foundation  of  pathology  and  therapeutics. 
It  is  striking,  and  we  do  not  hesitate  to  say  that,  in  our  opinion,  it  con- 
tains much  of  truth.  Whether  it  be  true  in  the  length  and  breadth  with 
which  the  author  presents  it  for  our  acceptance,  is  another  question.  We 
are  by  no  means  prepared  to  deny  that  in  some  forms  of  disease  there  is 
an  exaltation  of  the  vital  functions  of  the  affected  parts.  For  example,  it 
is  difficult  to  show  that  muscular  hypertrophy  does  not  involve  augmented 
activity  of  the  nutritive  processes  and  increased  functional  power,  and 
hence,  that  hypertrophy  is  to  be  regarded  as  a  partial  death,  but,  con- 
sidered in  its  practical  bearings,  the  doctrine  will  be  likely,  in  the  majority 
of  cases,  to  lead  to  safe  and  judicious  practice.  The  doctrine  seems  to  us 
to  have  grown  out  of  a  common  sense  view  of  clinical  medicine;  we  mean 
by  this  remark,  that  the  author  appears  to  have  set  about  to  devise  a  theory 
consistent  with  the  practical  notions  which  actuate,  at  the  present  moment, 
the  most  enlightened  and  judicious  physicians.  It  is  interesting  to  remark 
the  different  points  of  view  by  which  similar  practical  conclusions  are 
reached.  For  us  the  renewal  of  life  is  conservative  medicine,  and  the 
restoratist  is  the  conservative  physician.  Commending  the  theoretical 
part  of  the  work  to  the  reflections  of  the  reader,  we  shall  devote  the  re- 
mainder of  this  review  to  some  of  the  practical  points  presented  in  the 
remaining  twenty-seven  lectures. 

Continued  Low  Fever  is  the  subject  of  two  lectures.  The  author  is 
inclined  to  think  that  the  poison  of  continued  fever  enters  the  system 


1863.] 


Chambers,  The  Renewal  of  Life. 


389 


through  the  digestive  canal ;  and  he  believes  that,  at  an  early  stage,  the 
fever  may  be  arrested  by  an  emetic.  This  belief  is  for  us  especially  note- 
worthy, because  it  accords  with  the  opinion  of  one  who,  as  an  able,  candid, 
and  conscientious  clinical  observer,  is  second  to  none  other ;  we  refer  to 
James  Jackson,  of  Boston.  Dr.  Jackson  has  long  taught  that  continued 
fever  may  be  sometimes  broken  up  by  a  prompt  emetic.  We  regret  that 
we  have  nothing  to  say  on  this  point  from  our  own  experience. 

Regarding  the  blood  as  in  a  state  of  super-alkalinity  from  the  presence 
of  an  excess  of  ammonia,  according  to  the  remarks  of  Dr.  Richardson,  the 
introduction  of  an  acid  becomes  an  important  restorative  measure.  Dr. 
Chambers  gives  the  hydrocholoric  acid  in  doses  of  twenty  minims  every 
two  hours,  with  syrup.  Of  the  efficacy  of  this  measure  he  speaks  in  very 
strong  terms.  He  declares  that  during  a  period  of  eight  years  he  has  not 
lost  a  case  of  low  fever  in  which  this  remedy  has  been  taken  for  thirty-six 
hours. 

The  restorative  method  embraces  nutriment  containing  a  large  amount 
of  nitrogenized  material,  and  alcohol  when  there  is  prostration  with  deli- 
rium of  a  low  character.  The  latter  is  not  to  be  given  indiscriminately. 
We  are  glad  to  see  that  the  author  takes  ground  against  its  excessive  use ; 
but  it  seems  to  us  that  The  hardly  accords  to  it  sufficient  importance  in  the 
treatment.  A  number  of  cases  are  reported  as  illustrative  of  the  author's 
practice  in  low  continued  fever. 

Anaemia  and  bloodletting  are  discussed  in  one  lecture  With  respect  to 
the  former  there  is  nothing  to  be  especially  noted ;  but  from  the  author's 
views  of  bloodletting  we  must  express  dissent.   We  quote  his  language: — 

"The  question  (viz.,  why  we  bleed)  seems  to  me  rather  one  of  hydrostatics 
than  of  vital  statics.  The  primary  and  most  important  effect  is  mechanical. 
The  bloodvessels  of  some  parts  of  the  body  have  lost  their  tone  and  become 
dilated  ;  and  the  more  pressure  of  fluid  there  is  inside  them,  the  more  and  more 
will  their  vital  elasticity  be  impeded,  and  the  more  dilated  they  must  become. 
Taking  blood  in  this  case  is  like  emptying  the  urinary  bladder  when  paralyzed 
by  its  retained  contents ;  and  the  more  locally  the  remedy  can  be  applied,  the 
closer  it  resembles  that  approved  surgical  operation.  Relieved  of  the  burthen 
which  oppresses  their  life,  the  vessels  are  enabled  to  resume  their  function  of 
regulating  the  stream  of  the  circulation.  So  that  from  this  point  of  view,  and 
so  far,  the  treatment  is  directly  restorative  and  reconstructive.  It  is  a  remedy 
for  local  congestion." 

Dr.  Chambers  evidently  bleeds  more  than  most  practitioners  of  the  pre- 
sent day,  and  it  is  curious  to  see  how  he  essays  to  reconcile  his  practice 
with  his  doctrine  of  restoration  and  life  renewal.  He  shuts  out  of  view 
the  heart's  action,  the  force  of  attraction  in  the  tissues,  and  the  fact  that 
the  blood  contains  the  principles  of  repair.  We  are  among  those  who 
think  that  the  evils  of  bloodletting  are  apt  to  be  exaggerated,  and  that  its 
repudiation  in  all  cases  is  as  much  an  error  of  extremes  as  its  indiscriminate 
use.  But  we  must  say  that  the  mechanical  view  set  forth  in  the  foregoing 
extract  seems  to  us  untenable;  and  that  its  adoption,  as  the  basis  of  the 
employment  of  bloodletting,  would  be  productive  of  not  a  little  destructive 
practice. 

Rheumatic  Fever  is  the  subject  of  a  lecture.  Dr.  Chambers  attaches 
great  importance  to  quietude  and  protection  of  the  surface  against  cold. 
We  quote  his  practice  with  reference  to  these  objects  : — 

"The  patients  are  bedded  in  a  peculiar  fashion.  All  linen  is  strictly  forbid- 
den to  touch  the  skin.    A  slight  calico  shirt  or  shift  may  be  allowed ;  but  if 


390  Reviews.  [April 

they  possess  underclothing  only  of  the  prohibited  sort,  they  are  better  naked. 
Sheets  are  removed,  and  the  body  carefully  wrapped  in  blankets,  which  are  so 
arranged  as  to  shut  off  all  accidental  draughts  from  the  head.  The  newest  and 
fluffiest  blankets  that  can  be  got  are  used.  The  bed-clothes  being  put  so  are 
kept  so,  and  students  are  warned  that  when  they  listen  to  the  sounds  of  the 
heart  they  must  not  throw  open  the  blankets,  but  insert  their  stethoscope  (first 
warmed)  between  the  folds." 

He  adds : — 

"Since  I  have  instructed  my  nurses  to  adopt  it  (*.  e.  this  plan),  in  every  in- 
stance, during  the  last  eight  or  nine  years,  I  have  had  pericarditis  come  on  only 
in  one  patient  previously  sound,  and  that  was  in  a  girl  who  was  taking  mercury 
and  opium,  and,  I  suspect,  had  exposed  her  chest  a  good  deal  to  the  air." 

We  cannot  avoid  wishing  he  had  given  the  number  of  cases  under  his 
treatment  during  the  period  stated,  for  pericarditis  is  by  no  means  a  fre- 
quent complication  of  rheumatism.  In  addition  to  the  practice  just  de- 
scribed he  prescribes  the  alkaline  treatment,  and  gives  opium  as  a  palliative. 
The  iodide  of  potassium  he  thinks  useful  in  certain  cases.  If  pericarditis 
become  developed,  local  depletion  by  leeches  is  strongly  enforced.  The 
infrequency  of  this  complication,  however,  in  the  cases  under  his  observa- 
tion must  have  afforded  him  but  a  limited  opportunity  to  test  the  efficiency 
of  this  treatment.  We  must  confess  skepticism  as  to  the  power  of  blood- 
letting to  control  this,  more  than  other  serous  inflammations.  He  advises 
the  constant  application  of  a  poultice  to  the  prsecordia  during  the  con- 
tinuance of  the  pericarditis.  Mercury,  with  a  view  to  prevent  the  occur- 
rence of  pericarditis,  or  as  a  remedy,  he  does  not  employ,  having  observed 
a  fatal  case  in  which  this  complication  occurred  while  the  patient  was 
under  mercurial  influence.  Although  a  single  case  affords,  but  little  evi- 
dence either  for  or  against  a  remedy,  we  are  not  disposed  to  take  any 
exception  to  the  repugnance  with  which  he  regards  the  mercurial  treatment 
of  pericarditis. 

The  next  subject  considered  is  Pleurisy.  Leeches  and  poultices  consti- 
tute the  author's  treatment.  In  his  advocacy  of  the  former  he  reproduces, 
as  he  does  repeatedly  in  other  connections,  his  explanation  of  the  local 
detraction  of  blood  as  a  "renewer  of  life."    He  says: — 

"Doubtless  the  taking  away  the  vital  fluid  is  taking  away  part  of  the  body, 
and  so  is  directly  a  destructive  agent.  But,  then,  blood  thus  lost  from  an  in- 
flamed part  is  not  all  loss ;  it  is  black  '  melanose,'  partially  dead  and  unfitted 
for  the  purposes  of  life,  and  only  a  portion  of  it  can  be  called  living.  Then 
again,  granting  that  loss  of  blood  is  a  direct  loss  to  a  living  body,  still  the  indi- 
rect gain  is  a  full  compensation  to  cases  when  it  is  rightly  applied.  The  blood- 
vessels resume  their  elastic  force,  the  blood-stream  is  restored,  and  loss  of  sub- 
stance is  a  regaining  of  function.  So  that  a  destructive  becomes  in  the  end  a 
constructive  remedy." 

But  does  it  follow  that,  because  leeches  are  applied  to  the  chest,  the 
blood  removed  comes  from  the  inflamed  place  ?  Is  it  only  the  melanoid 
or  partially  dead  blood  which  is  removed?  Does  the  blood  taken  from  the 
integument  of  the  chest  in  pleurisy  show  evidences,  derived  from  micro- 
scopical or  chemical  examination,  of  partial  death,  or  any  essential  change? 

The  explanation  given  of  the  modus  operandi  of  poultices  is,  to  say  the 
least,  amusing: — 

"In  the  action  of  poultices  there  is  no  even  seeming  paradox  to  stumble  at. 
Continuous  steady  warmth  is  the  most  direct  agent  we  possess  of  vital  develop- 
ment.   It  not  merely  encourages  vital  growth,  but  makes  that  growth  take  a 


1863.] 


Chambers,  The  Renewal  of  Life. 


391 


higher  form  of  life.  Mr.  Higginbottom  found  that  different  detachments  of  tad- 
poles, kept  in  the  dark  and  treated  with  different  degrees  of  temperature,  threw 
off  their  tails  and  branchiae,  and  developed  lungs  and  became  frogs  with  a  quick- 
ness exactly  proportioned  to  the  warmth  they  were  subjected  to.  Warmth, 
especially  when  kept  steady,  and  even  by  moisture  joined  with  it,  has  the  same 
effect  on  the  failing  life  of  tissues ;  it  raises  and  restores  it  to  its  normal  force 
of  development.  It  renews  the  injured  membrane  which  had  been  lowered  to 
that  condition  we  call  congestion  and  inflammation  into  the  higher  life  of  warm- 
blooded circulation.  As  it  developed  the  tadpole  into  the  frog,  so  it  develops 
the  half-killed  diseased  part  into  full  life." 

Dr.  Higginbottom,  we  fancy,  hardly  dreamed  of  this  practical  application 
of  the  results  of  his  experiments  on  tadpoles  ! 

Here,  as  in  other  instances,  Dr.  Chambers  affirms  with  much  positiveness 
the  efficacy  of  his  mode  of  practice.  "  Such  means,"  he  says  (i.  e.  leeches 
and  poultices),  "will  not  fail  to  cut  short  an  attack  of  pure  pleurisy."  We 
must,  however,  dissent  in  toto  from  his  implied  opinion  that  acute  pleurisy 
teuds  to  the  destruction  of  life.  He  gives  a  case  in  which  it  proved  rapidly 
fatal ;  but  in  that  case  there  existed  pyaemia.  Fatal  cases  of  pure  acute 
pleurisy  are  exceptional.  Dissenting  from  his  opinion  of  the  danger  of 
pleurisy,  we  must  also  dissent  from  him  when  he  says,  "Do  not  hesitate 
and  trust  patients  to  Nature  in  any  disease  ;  but  least  of  all  in  acute  pleu- 
risy." On  the  contrary,  we  could  cite  abundant  facts  to  show  that  cases 
of  acute  pleurisy  may  generally  be  left  to  Nature  with  entire  safety. 

Idiopathic  hydrothorax  Dr.  Chambers  considers  as  meaning  "  a  collec- 
tion of  serum  in  the  pleural  sac,  injurious  to  health  from  its  quantity,  and 
arising  from  an  abnormal  state  of  the  pleura  itself."  By  this  definition  he 
excludes  dropsy  of  the  pleural  sac,  and  applies  the  term  hydrothorax  to 
an  effusion  which  in  most,  if  not  all  cases,  proceeds  from  pleuritis.  We 
are  unable  to  see  the  propriety  of  this  use  of  the  term.  Subacute  or  chronic 
pleurisy  with  effusion,  as  it  seems  to  us,  covers  the  ground  sufficiently.  In 
the  treatment  of  these  cases  he  employs  blisters,  poultices,  and  diuretics. 
Recollecting  his  antipathy  to  mercury  in  pericarditis,  we  are  surprised  at 
his  very  strong  recommendation  of  this  remedy  in  pleuritic  effusion.  We 
quote  his  remarks: — 

"Mercury  distances  all  the  contents  of  our  Pharmacopoeia  in  the  power  of 
hastening  destructive  metamorphosis.  Under  its  influence  all  .the  excretions 
are  increased  at  the  expense  of  the  tissues.  Now  it  is  quite  true  that,  by  such 
a  process,  nothing  is  directly  gained  in  cases  like  that  before  us ;  there  is  no 
poison  to  evacuate,  and  the  debility  which  follows  is  so  much  ground  lost. 
Harm,  therefore,  certainly  is  done  by  it;  but  with  the  harm  there  is  joined  a 
good  which  I  think  is  worth  the  loss.  No  drug  so  constantly  and  steadily 
promotes  absorption  as  mercury,  and  in  no  case  can  you  trace  its  effects  so 
easily  as  in  hydrothorax." 

We  cannot  but  think  that  the  loss  from  mercurialization  in  these  cases 
is  more  appreciable  than  the  gain,  and  we  believe  that  Dr.  Chambers  will 
think  so  if  he  will  observe  a  series  of  cases  treated  without  having  recourse 
to  mercury.  He  reports  a  case  in  which  paracentesis  was  employed,  and 
considers  this  to  be  an  easy  and  safe  operation. 

Acute  Laryngitis  is  the  next  subject  considered.  The  therapeutical  in- 
junctions are  thus  summed  up: — 

"  Warm  the  surface  of  the  body ;  saturate  with  hot  steam  the  air  inspired  ; 
put  on  leeches  and  hot  fomentation  to  the  throat.  Food  must  be  sedulously 
administered,  if  not  by  mouth  by  rectum.  If  benefit  do  not  quickly  follow, 
perform  tracheotomy,  or  get  it  performed." 


392 


Reviews. 


[April 


We  would  commend  especially  the  last  injunction  ;  many  lost  lives  might 
have  been  saved  by  a  prompt  resort  to  this  operation. 

The  author  objects  to  the  use  of  antimony  and  mercury  in  this  disease, 
and  the  grounds  of  his  objection  are  precisely  those  which  we  have  been 
led  to  consider  as  warranting  their  use.  He  thinks  that  these  remedies 
depress  rapidly  the  general  vitality,  and  his  argument  against  their  appli- 
cability in  acute  laryngitis  is  contained  in  the  following  quotation  : — 

"  This  depression  is  the  more  decided  from  the  limited  extent  of  the  inflamed 
spot,  and  the  limited  inflammatory  reaction  on  the  system ;  for  the  poisonous 
actions  of  antimony  and  mercury  are  the  stronger  in  inverse  proportion  to  the 
amount  of  tissue  inflamed.  Give  them  to  a  healthy  man — to  a  man  with  a 
cold  in  the  head  or  an  inflamed  corn — and  they  pull  him  down  most  wonder- 
fully ;  but  give  them  to  a  patient  with  double  pneumonia  or  peritonitis,  and  he 
hardly  feels  their  effect.  •  In  laryngitis,  therefore,  more  than  in  most  inflamma- 
tions, these  drugs  are  likely  to  have  a  deleterious  action,  and  less  than  in  most 
inflammations  a  beneficial  action." 

In  direct  contrast  with  this  reasoning  we  should  argue  in  behalf  of  the 
appropriateness  of  these  remedies  in  acute  laryngitis,  as  follows:  Since  the 
inflammation  in  acute  laryngitis  involves  no  danger  per  se,  but  only  because, 
from  its  situation,  it  occasions  obstruction  to  respiration,  it  is  not  so  much 
an  object  to  spare  the  powers  of  life  as  in  other  affections  like  pneumonia  or 
peritonitis,  which  destroy  life  by  asthenia,  We  cannot  appreciate  the  effects 
of  the  remedies  in  question  in  the  latter  diseases  so  well  as  when  a  patient 
has  only  a  common  cold  or  an  inflamed  corn,  because  their  effects  are  in- 
termixed with  the  phenomena  of  the  disease,  but  in  proportion  as  the 
disease  tends  to  impair  the  general  vitality,  the  latter  has  less  force  of 
resistance  to  these  remedies.  We  would,  therefore,  reverse  the  closing 
statement  in  the  question  and  say,  in  laryngitis  less  than  in  most  inflamma- 
tions, these  drugs  are  likely  to  have  a  deleterious  action,  and  more  than  in 
most  inflammations,  a  beneficial  action.  We  submit  the  alterem  partem 
to  the  verdict  of  the  reader. 

Pneumonia,  is  the  subject  of  the  next  lecture.  Dr.  Chambers  is  an  ad- 
vocate for  bleeding  in  this  disease.    We  give  the  theory  of  its  usefulness. 

"  The  beneficial  action  of  bloodletting  in  pneumonia  is  mechanical.  The 
pathology  of  the  demand  for  its  use  is  as  follows :  by  the  temporary  death  of  a 
portion  of  the  lungs  the  blood  cannot  be  quickly  enough  passed  onward  through 
their  tissue ;  it  can  run  freely  as  far  as  the  right  side  of  the  heart,  but  there  it 
is  stopped  ;  .the  throng  pressing  onward  from  behind  makes  matters  worse,  and 
thus  the  balance  between  the  venous  and  arterial  heart  is  destroyed.  *  *  * 
Take  away  some  of  the  blood  from  the  veins  and  the  balance  is  restored ;  the 
pulse  becomes  '  freer,'  as  the  technical  phrase  is  ;  that  is  to  say,  the  heart  being 
relieved  of  the  undue  crowd  in  the  right  side,  is  not  arrested  in  its  contraction, 
but  is  able  to  close  upon  its  contents  and  supply  them  steadily  to  the  arteries." 

This  explanation  is  not  peculiar  to  Dr.  C.  We  believe  it  to  be  rational, 
and  a  sufficient  ground  for  bleeding  when  other  circumstances  do  not  contra- 
indicafe  it.  We  will  add  a  consideration,  which  we  suspect  to  be  of  im- 
portance, with  reference  to  bleeding  in  pneumonia.  The  accumulation  of 
blood  in  the  right  cavities  of  the  heart  favours  the  occurrence  of  heart-clot, 
which  we  are  well  convinced  is  an  accident  occurring  in  this  disease  oftener 
than  is  generally  supposed.  A  sudden  and  unexpectedly  fatal  termination 
is  not  unfrequently  attributable  to  this  accident. 

Aside  from  the  question  of  bloodletting,  the  author  advises  nutriment, 
wine,  and  a  poultice  to  the  chest.  He  abstains  from  purgatives,  blisters, 
antimony,  and  mercury,  to  which  we  cordially  say,  amen. 


1863  ]  Chambers,  The  Renewal  of  Life.  393' 


The  lecture  on  pulmonary  consumption  is,  in  our  estimation,  one  of  the 
most  valuable  in  the  book.  The  following  sentence,  which  the  author 
gives  in  italics,  indicates  the  line  of  conduct  which  the  practitioner  should 
pursue  in  the  management  of  this  disease.  "I  cannot  too  strongly  impress 
upon  you  that  not  so  much  the  tubercle  as  the  tendency  to  form  tubercle, 
nor  the  morbid  matter,  but  the  diathesis,  is  that  which  should  occupy  your 
thoughts.71  In  pursuing  this  line  of  conduct  we  agree  with  the  author 
most  heartily  in  avoiding  all  so-called  "cough  medicines,"  such  as  anti- 
mony, ipecacuanha,  and  squill ;_  also,  mercury  and  purgatives.  We  agree 
with  him  when  he  says  that  the  object  is  "  to  get  the  greatest  possible 
amount  of  albuminous  food  fully  digested  and  applied  to  the  renewal  of 
the  body."  Cod-liver  oil  he  deems  often  useful  as  a  form  of  nutriment.  We 
believe  that  he  underestimates  the  value  of  alcohol  as  a  remedy  is  this  dis- 
ease. 

The  lecture  on  Disease  of  the  Heart  is  excellent.  He  cites  a  series  of 
cases  in  which  organic  murmurs  had  existed  for  many  years  without  incon- 
venience from  valvular  lesions.  We  have  endeavoured  to  impress  the  error 
and  evils  of  attaching  undue  significance  to  heart-murmurs,  and  to  enforce 
the  importance,  in  cases  of  chronic  valvular  lesions,  of  keeping  the  heart  and 
the  system  at  large  invigorated  as  much  as  possible.  We  quote  with  satis- 
faction the  following  enumeration  of  the  main  points  in  the  management 
of  diseased  hearts  : — 

"  1.  The  importance  of  valvular  lesions  consists  in  their  liability  to  cause  en- 
largement of  the  organ. 

"2.  Ih  auscultation  we  should  strive  more  to  find  out  the  state  of  the  heart- 
walls  than  of  the  valves.1 

"  3.  The  danger  of  enlargement  is  greatest  where  the  muscular  fibre  is 
weakest. 

"  4.  The  muscular  fibre  is  weakest  where  the  blood  is  most  anaemic. 
"  5.  The  principal  object  of  treatment  is  to  avoid  anaemia." 

Passing  by  a  lecture  on  thoracic  aneurism,  the  two  next  lectures  are  de- 
voted to  Albuminuria  and  Diabetes.  The  practical  views  with  respect  to 
the  former  of  these  two  diseases  accord  with  those  now  generally  held  by  in- 
telligent practitioners,  nor  do  we  find  anything  especially  noteworthy  in  the 
lecture  on  the  latter  disease.  We  may  dismiss,  in  the  same  manner,  the 
subjects  treated  of  in  the  two  succeeding  lectures,  viz.,  Hysteria  and 
Sciatica. 

The  last  nine  lectures  are  devoted  to  the  digestive  organs.  Hie  Im- 
portance of  these  Organs  in  Therapeutics  is  the  subject  of  a  lecture.  Indi- 
gestion occupies  three  lectures,  and  Eructation  and  Vomiting  an  additional 
lecture.  The  Dietetics  of  Deranged  Digestion  are  considered  in  another 
lecture.  Pepsine  and  Alcohol  each  occupy  a  lecture ;  and  finally,  Diar- 
rhoea and  Constipation  have  each  a  distinct  lecture.  Our  limits  forbid  a 
reviewal  of  these  nine  lectures,  and  the  more  because  they  are  even  richer 
than  the  preceding  lectures  in  practical  points  of  interest  and  importance. 
Dr.  Chambers,  as  we  need  not  inform  our  readers,  has  made  digestion  and 
its  derangements  a  special  study,  and  the  last  nine  lectures  of  this  book 
may  be  regarded  as  an  appendix  to  his  former  valuable  treatise  on  the  same 
subject. 

As  a  writer,  Dr.  Chambers  is  remarkable  for  presenting  his  views  with 
great  boldness,  precision,  and  conciseness.    He  gives  many  valuable  facts, 

1  The  physical  signs  enable  us  to  find  out  both. — Reviewer. 


394 


Reviews. 


[April 


and  much  that  is  suggestive  of  important  trains  of  reflection  within  a  small 
compass.  His  writings  excite  and  sustain  the  reader's  attention.  In  his 
little  work  on  the  Renewal  of  Life  he  treats  of  the  various  subjects  in  a 
fragmentary  style,  confining  himself  to  the  salient  points  of  inquiry;  but 
this  feature  of  the  work,  arising  from  the  fact  of  its  being  made  up  of 
clinical  lectures,  will  hot  render  it  less  attractive  to  the  medical  reader. 
The  work  is,  in  many  respects,  open  to  criticism.  The  soundness  of  the 
author's  reasoning  may  not  unfrequently  be  called  in  question,  and  there 
seem  to  us  to  be  palpable  inconsistencies  between  the  doctrine  of  "restora- 
tive medicine"  and  the  author's  practice.  But  it  is  a  work  well  suited  to 
awaken  thought  and  inquiry  in  a  right  direction,  and  we  are  not  surprised 
to  hear  that  already  it  has  passed  to  a  second  English  edition.  So  soon 
as  our  domestic  troubles  permit  the  medical  publishers  of  this  country  to 
resume  their  wonted  activity,  we  shall  expect  to  see  the  work  in  an  Ameri- 
can dress.  A.  F. 


Art.  XV. — Medico-  Chirurgical  Transactions.  Published  by  the  Royal 
Medical  and  Chirurgical  Society  of  London.  Yol.  XLY.  (2d  Series, 
Yol.  the  twenty-seventh.)    London,  1862.    8vo.  pp.  497. 

This  volume  contains  twenty-four  original  communications.  Abstracts 
of  fourteen  of  these  having  been  already  given  in  the  quarterly  summaries 
in  numbers  of  this  Journal  for  last  year,  we  shall  now  notice  only  the  other 
papers  in  the  volume. 

I.  Observations  in  the  discovery  of  the  original  obstetric  instruments 
of  the  Ghamberlens.  By  Robert  Lee,  M.  D. — This  paper,  as  detailing 
several  circumstances  connected  with  the  history  of  the  Chamberlens,  and 
with  the  introduction  of  the  midwifery  forceps  in  the  practice  of  obstetrics, 
will  be  read  with  interest,  particularly  by  those  who  study  and  practice  that 
department  of  medical  science.  Dr.  Lee  does  not  appear  to  question  at 
all  that  the  Chamberlens  were  the  first  to  use  forceps. 

II.  On  certain  grave  evils  attending  Tenotomy,  and  on  a  new  method 
of  curing  Deformities  of  the  Foot.  By  Richard  Barwell,  F.  R.  C.  S.  E. 
— An  abstract  of  this  paper  is  published  in  the  number  of  this  Journal  for 
January,  1862.  It  is  one  of  importance,  as  calling  attention  forcibly  to 
the  too  much  neglected  fact  that,  in  certain  cases  of  deformity  of  the  foot, 
division  of  the  tendons  only  aggravates  the  patient's  condition,  and  also 
as  indicating  a  most  promising  mode  of  treatment ;  instead  of  destroying 
by  an  incision  the  action  of  the  muscles  by  which  the  foot  is  turned,  Mr. 
Barwell,  by  an  ingenious  apparatus,  assists  the  action  of  those  that  are  not 
sufficiently  powerful  to  keep  it  straight.  In  this  apparatus,  which  is  not 
very  clearly  described  in  the  volume  before  us,  and  still  less  clearly  in  the 
abstract  referred  to,  an  inextensible  piece  of  stout  adhesive  plaster  is  fast- 
ened to  the  foot  all  over  the  course  of  the  tendon  of  the  feeble  muscle,  and 
an  elastic  cord,  following  the  course  of  the  muscle,  is  fastened  to  the  end 
of  the  plaster  below  and  to  a  hook  above.  This  hook,  in  the  apparatus 
described  by  Mr.  Barwell,  is  held  in  position  by  being  attached  to  the  upper 
extremity  of  a  piece  of  tinned  iron  bound  to  the  leg  by  adhesive  strips* 
If  this  hook,  to  which  the  upper  extremity  of  the  elastic  band  is  attached, 


1863.] 


Medico-Chirurgical  Transactions, 


395 


were  held  in  place  by  some  contrivance  not  interfering  with  the  free  play 
of  the  muscles  of  the  leg,  the  apparatus,  it  seems  to  us,  would  be  much 
improved.  Mr.  Barwell's  paper  is  accompanied  by  a  plate  containing  five 
figures,  illustrating  the  application  of  the  apparatus  in  various  malpositions 
of  the  foot. 

III.  Congenital  Malformation  of  the  Eyes  in  three  children  of  one 
family.  By  Thomas  Nunneley,  F.  R.  C.  S.  E. — The  malformation  in  the 
three  cases  mentioned  in  this  paper  consisted,  in  one,  in  total  absence  of  the 
iris  in  both  eyes,  and  in  the  others  in  the  irides  being  dull,  thin,  and  tremu- 
lous. Though  the  eyes  in  all  the  cases  were  irritable  and  painfully  affected 
by  very  strong  light,  yet  vision  was  pretty  good.  In  the  work  of  Des- 
marres  on  diseases  of  the  eye,  the  frequency  with  which  irideremia  is  seen 
in  several  members  of  a  family  is  spoken  of,  and  a. most  curious  example 
is  given,  to  which  we  would  refer  those  particularly  interested  in  this  affec- 
tion, and  also  those  interested  in  the  interesting  study  of  the  inheritance 
of  deformities.  (Desmarres,  Mai.  des  Yeux.  Tome  deuxieme,  page  457. 
Paris,  1855.) 

IV.  Observations  on  the  division  of  the  Gustatory  Nerve,  and  on  liga- 
ture of  the  Lingual  Artery,  in  the  treatment  of  Cancer  of  the  Tongue. 
By  Charles  H.  Moore,  F.  R.  C.  S.  E. — An  abstract  of  this  paper  is  pub- 
lished in  the  number  of  this  Journal  for  January,  1862.  The  operations 
recommended  by  Mr.  Moore,  though  not  curative,  yet  have  afforded  such 
decided  relief,  that  surgeons  should  be  encouraged  to  practise  them,  as 
making  life  less  insupportable  in  one  of  the  most  distressing  affections  to 
which  the  human  body  is  liable. 

A  plate  is  attached  to  this  communication,  representing  a  vertical  median 
section  of  the  bones  of  the  face,  for  the  purpose  of  marking  the  place 
where  the  gustatory  nerve  is  recommended  to  be  divided. 

Y.  A  case  of  Osteo-malacia.  By  Robert  Barnes,  M.  D.  Communi- 
cated by  Mr.  T.  B.  Curling,  F.  R.  S. — Dr.  Barnes  has  submitted  the  very 
interesting  case  of  osteo-malacia,  here  recorded,  to  the  Royal  Medical  and 
Chirurgical  Society  for  the  reason  that  in  the  Transactions  of  this  Society 
is  to  be  found  a  great  part  of  all  the  original  information  that  has  been 
contributed  by  English  authors  concerning  that  rare  and  formidable  disease.1 

The  patient  was  a  woman,  forty  years  of  age,  married,  but  never  preg- 
nant, who  had  enjoyed  good  health,  and  who  belonged  to  a  healthy  family. 
The  clavicles,  the  scapulas,  and  the  bones  of  the  head  and  the  extremities 
were  not  affected  by  the  disease,  and  those  bones  of  the  trunk  suffered  most 
the  bulky  part  of  which  is  largely  formed  of  cancellous  tissue.  Under  the 
use  of  cod-liver  oil,  which  has  been  recommended  by  Breslaw  and  others 
as  beneficial  in  cases  of  softening  of  the  bones,  the  progress  of  the  disease 
was  arrested,  and  the  patient  restored  to  health. 

The  most  interesting  portion  of  the  paper  is  the  account  of  the  analysis 
of  the  urine  made  at  various  times.  The  characters  of  this  secretion  may 
be  briefly  summed  up  as  follows  :  During  the  active  stage  of  the  disease  it 
contained  a  large  excess  of  urea,  of  alkaline  and  earthy  phosphates,  and 
of  extractive.  It  also  almost  constantly  contained  small  quantities  of 
sugar.  It  is  worthy  of  note  that  in  a  case  related  by  Beylard,  who  has 
written  by  far  the  most  complete  account  of  osteo-malacia  that  has  yet 
been  published,  a  number  of  calculi  were  removed  from  the  kidneys  after 
death.    These  calculi  were  found,  on  chemical  analysis,  "to  be,  so  to  speak, 

1  See  vols,  vii.,  viii.,  xv.,  xvii.,  and  xx.  for  papers  on  the  subject. 


396 


Reviews. 


[April 


exempt  from  uric  acid,  and  from  ammoniaco-magnesian  phosphates,  and  to 
be  formed  entirely  of  phosphate  of  lime  and  of  organic  matter."1 

VI.  On  some  affections  of  the  Csecal  portions  of  the  Intestines.  With 
illustrative  cases.  By  Frederick  George  Reed,  M.  D. — A  full  abstract 
of  this  important  paper  is  published  in  the  number  of  this  Journal  for 
April,  1862.  In  an  appendix  attached  to  the  paper  in  the  volume  before 
us,  the  reasons  are  given  why  Sir  Benjamin  Brodie  recommends  patients 
with  caecal  fistula  to  remain  recumbent  on  the  face  night  and  day  for  seve- 
ral months,  and  also  for  the  administration  of  one  drachm  doses  of  pow- 
dered cubebs.  In  all  those  cases  of  rupture  of  the  cascum  followed  by 
abscess,  which  Sir  Benjamin  Brodie  has  had  the  opportunity  of  examining 
after  death,  on  dissection,  the  opening  has  been  uniformly  at  the  posterior 
part  of  the  intestine;  consequently,  the  object  of  the  patient  maintaining 
the  prone  position  on  the  face  becomes  obvious.  The  use  of  powdered 
cubebs  pepper  was  suggested  from  it  having  been  found  to  be  often  very 
beneficial  in  cases  of  internal  piles,  and  especially  useful  when  the  patient 
suffers  from  hemorrhage  in  consequence.  The  powdered  cubebs  pepper 
seems  to  act  by  mixing  with  the  feces  and  becoming  a  topical  application 
to  the  mucous  membrane  of  the  bowel.  In  the  case  related  by  Dr.  Reed 
the  grains  of  pepper  were  daily  recognizable  in  the  fecal  matter  passing 
through  the  fistulous  opening.  The  medicine  appeared  to  be  grateful  to 
the  stomach,  and  to  aid  the  action  of  the  bowels. 

VII.  and  VIII.  On  the  Poisonous  Effects  of  Goal-Gas  upon  the  Ani- 
mal System;  and  Additional  Experiments  on  the  Poisonous  Effects  of 
Coal- Gas  upon  the  Animal  System.  By  C.  J.  B.  Addis,  M.  D. — Ab- 
stracts of  these  papers  upon  the  effects  of  undiluted  coal-gas,  and  the  effects 
of  the  same  gas  diluted  with  atmospheric  air  in  different  proportions, 
togetl*er  with  the  remarks  made  by  Mr.  Marcet  and  others  at  the  time  of 
their  reading  before  the  Society,  are  published  in  the  numbers  of  this  Journal 
for  April  and  for  July,  1862. 

IX.  On  the  Temperature,  Urea,  Chloride  of  Sodium,  and  Urinary 
Water  in  Scarlet  Fever;  and  on  a  Cycle  in  Disease  and  Health.  By 
Sidney  Ringer,  M.  B.  Communicated  by  Dr.  Garrod,  F.  R.  S. — An 
abstract  of  the  experiments  recorded  in  this  very  elaborate  paper,  which  is 
intended  to  be  a  sequel  of  a  former  paper  on  "Ague,"  published  by  the 
author  in  Volume  XLII.  of  the  Transactions,  of  which  a  notice  was  given 
in  this  Journal  in  the  number  for  April,  1860,  is  published  in  the  number 
of  this  Journal  for  April,  1862.  , 

This  communication  is  accompanied  by  nine  diagrams,  or  charts,  by 
which  the  study  of  the  changes  in  temperature  from  day  to  day  is  greatly 
facilitated. 

In  connection  with  this  subject,  it  may  be  thought  worthy  of  mention 
that  we  have  recently  examined,  on  two  occasions,  the  urine  passed  by  a 
patient  during  the  long-continued  cold  stages  of  pernicious  intermittent 
fever.  In  both  instances  it  was  found  to  have  a  specific  gravity  of  1030, 
and  the  excess  was  determined  to  be  owing  to  the  large  quantity  of  urate 
of  soda  it  contained. 

X.  On  Pulse-Breath.  By  C.  Radcliffe  Hall,  M.  D.  Communicated 
by  W.  Jenner,  M.  D. — By  the  term  "pulse-breath,"  Dr.  Hall  wishes  to 

1  Beylard,  "  Du  rachitis,  de  la  fragilite  des  os,  de  l'osteomalacie."  Paris,  1852. 
It  is  quite  remarkable  that  Dr.  Barnes  manifests  no  acquaintance  with  this  really 
splendid  monograph. 


1863.] 


Medico -Chirurgical  Transactions. 


391 


signify  an  audible  pulsation  communicated  to  the  breath,  as  it  issues  from 
the  mouth,  by  each  beat  of  the  heart.  It  must  not  be  mistaken  for  "pulse- 
respiration,"  which  is  often  used  to  designate  the  ratio  that  exists  between 
the  frequency  of  the  pulse  and  the  number  of  the  respirations  in  a  given 
time.  It  is  simply  an  audible  pulsation  of  the  breath  as  it  issues  from  the 
patient  while  he  holds  his  mouth  open  and  breathes  as  gently  and  with  as 
little  of  the  ordinary  noises  of  respiration  as  possible.  The  sound  is  that 
of  a  gentle  gushing  of  the  breath  synchronous  with  each  pulsation  of  the 
heart,  and  such  as  any  one  may  imitate  voluntarily,  so  far  as  the  character 
of  the  sound  is  concerned. 

Dr.  Hall  has  noticed  the  phenomenon  he  terms  "pulse-breath"  in  three 
cases.  In  two  there  was  a  large  excavation  in  the  lungs,  and  as  the  cavity 
was  more  empty  so  the  sound  was  more  marked.  After  an  attack  of 
vomiting,  by  which  the  cavity  was  well  cleared  of  its  liquid  contents,  Dr. 
Hall  was  able  to  count  the  pulse  of  the  patient  by  listening  to  his  breath 
at  a  distance  of  fifteen  feet.  The  mechanism  of  the  production  of  pulse- 
breath  in  these  cases  seems  to  be  very  evident.  A  large  cavity,  old  enough 
to  possess  walls  of  sufficient  density,  which  is  not  immediately  separated 
from  the  heart  by  permeable  or  crepitating  lung,  or  any  other  intermediate 
soft  texture  which  could  act  the  part  of  a  damper,  and  which  is  tolerably 
dry  for  the  moment  by  being  emptied  of  its  customary  contents,  vibrates 
in  accordance  with  each  beat  of  the  heart,  and  at  each  vibration  throws 
the  air  in  the  cavity,  trachea,  larynx,  and  mouth,  into  a  sonorous  pulsa- 
tion. When  the  cavity  is  more  or  less  filled  with  liquid,  it  no  longer 
vibrates ;  and,  as  this  is  the  habitual  state  of  a  cavity  which  has  not  col- 
lapsed, the  phenomenon  of  pulse-breath  is  not  ordinarily  present  even  in 
such  cases  as  can  manifest  it  under  fitting  conditions. 

The  next  example  of  "pulse-breath"  related  by  Dr.  Hall  is  less  easy  of 
explanation.  The  case  was  one  of  cardiac  disease  with  enlarged  liver,  pul- 
monic congestion,  relieving  itself  occasionally  by  haemoptysis,  leaky  kid- 
neys, and  general  anasarca  of  the  lower  extremities.  In  this  patient  a  soft, 
gentle  "pulse-breath"  was  never  absent  when  the  mouth  was  held  open. 
It  was  audible  when  the  patient  was  asleep,  and  when  awake  it  was  ren- 
dered considerably  louder  when  the  action  of  the  heart  was  unusually 
excited.  To  explain  the  production  of  "pulse-breath"  in  this  case  it  may 
be  supposed  that  the  impulse  of  the  distended  auricles  and  the  pulsation  in 
the  pulmonic  vessels  were  communicated  through  the  condensed  luug  to 
the  air  in  the  bronchial  tubes  at  the  same  instant  of  time  that  the  pulse 
was  communicated  through  the  bloodvessels. 

The  phenomenon  to  which  attention  is  called  by  this  paper,  though  we 
are  not  aware  that  it  possesses  any  special  diagnostic  or  prognostic  im- 
portance, inasmuch  as  the  nature  of  the  case  will  probably,  in  every  instance, 
be  sufficiently  evident  without  it,  is  at  least  one  of  very  considerable  interest 
as  a  medical  problem  alone. 

XI.  The  Brassfounders>  Ague.  By  Edward  Headlam  Greenhow, 
M.  D. — An  abstract  of  this  communication,  in  which  attention  is  again 
called  to  the  irregular  paroxysms,  resembling  the  paroxysms  of  ague, 
affecting  those  exposed  to  inhaling  the  fumes  of  deflagrating  zinc,  is  pub- 
lished in  the  number  of  this  Journal  for  July,  1862. 

XII.  On  the  Connection  between  a  Local  Affection  of  the  Lymphatic 
System  and  Chylous  Urine;  with  Remarks  on  the  Pathology  of  the  Dis- 
ease. By  H.  Y.  Carter,  M.  D.,  Professor  of  Anatomy  and  Physiology, 
Bombay  Medical  College.    Communicated  by  Prescott  G.  Hewett,  F.  R. 


398 


Reviews. 


[April 


C.  S. — In  this  communication  Dr.  Carter  gives  the  history  of  three  cases 
of  disease  of  the  lymphatic  system,  and  then  proposes  a  new  view  of  the 
nature  of  the  obscure  disease  characterized  by  a  chylous  condition  of  the 
urine. 

The  first  case  is  a  well-marked  instance  of  local  derangement  of  the  lym- 
phatic system,  accompanied  by  the  accumulation  of  chyle,  and  its  occasional 
discharge  from  the  cutaneous  surface.    The  urine  was  unaffected. 

In  the  second  case,  a  local  affection  of  the  lymphatic  vessels  and  glands 
existed,  and  there  was  a  frequent  external  discharge  of  chyle.  The  urine, 
moreover,  in  this  case  was  frequently  chylous,  in  the  strict  sense  of  the 
word. 

In  the  other  case,  without  any  external  local  affection  of  the  lymphatics, 
the  patient  presented  a  striking  instance  of  chylous  urine,  which,  as  in  the 
other,  was  intermitting  in  character. 

The  view  advanced  by  Dr.  Carter  is,  that  chylous  urine  is  connected 
with  an  abnormal  distribution  of  the  chyle,  which  becomes  admixed  with 
the  urine  in  a  direct  manner,  and  not  through  abnormal  excretion  of  the 
chyle,  as  Prout  supposed,  or  through  its  absorption,  as  is  maintained  by 
Dr.  Beale. 

In  the  cases  where  the  chyle  was  poured  only  on  the  surface  of  the  body — 
on  the  thigh  and  the  scrotum — lymphatic  vessels  and  the  glands  could  be 
seen  to  be  greatly  enlarged  and  dilated,  and  this  state  must  have  extended 
upwards,  as  high  indeed  as  the  thoracic  duct,  for  the  fluid  discharged  was 
not  mere  lymph,  but  a  rich  chylous  liquid.  Of  course  if  the  chyle,  in  place 
of  being  poured  out  externally,  had  been  turned  upon  the  urinary  mucous 
tract,  where  local  hypertrophy  and  dilatation  of  the  lymphatic  system  might 
readily  exist,  for  the  lymphatics  of  the  bladder,  ureters,  &c,  are  very  nume- 
rous and  superficial,  all  the  phenomena  of  chylous  urine  would  have  been 
witnessed.  Although  direct  anatomical  proof  of  the  accuracy  of  these 
views  has  not  been  obtained,  they  must,  nevertheless,  be  acknowledged  to 
afford  a  more  satisfactory  explanation  of  the  phenomena  observed  in  chylous 
urine  than  any  hitherto  offered. 

This  paper  is  accompanied  by  a  plate  representing  the  appearance  of  the 
parts  affected  in  one  of  the  patients,  and  also  the  microscopical  appearances 
of  the  fluid  discharged,  both  externally  and  from  the  bladder. 

XIII.  On  a  Case  of  Chylous  Urine.    By  A.  T.  H.  Waters,  M.  D  

In  the  case  here  related  of  chylous  urine,  the  patient  became  well  while 
taking  very  large  doses  of  an  astringent  remedy,  gallic  acid ;  sometimes  to 
the  amount  of  135  grains  per  diem.  On  this  account,  Dr.  Waters  argues 
that  the  affection  is  one  whose  main  pathological  feature  is  a  relaxed  con- 
dition of  the  capillaries  of  the  kidneys. 

XIV.  Observations  on  the  Tactile  Sensibility  of  the  Hand.  By  Edward 
Ballaud,  M.  D. — A  short  abstract  of  this  most  elaborate  paper,  which 
occupies  nearly  sixty  pages  of  this  volume,  is  published  in  the  number  of 
this  Journal  for  July,  1862. 

Two  plates,  each  containing  two  figures,  are  attached  to  this  communi- 
cation, showing  the  precise  spots  at  which  measurements  of  the  sensibility 
of  the  hand  were  taken,  with  a  number  affixed  giving  the  two  measure- 
ments, by  which  the  sensibility  of  each  spot  is  calculated.  The  palmar  and 
the  dorsal,  and  the  radial  and  the  ulnar  sides  of  the  hand  and  fingers,  are 
thus  represented.  These  plates  are  reduced  from  photographs,  so  as  to  be 
undoubtedly  accurate. 


1863.] 


Medico-Chirurgical  Transactions. 


399 


XY.  On  the  Influence  of  Paralysis,  Disease  of  the  Joints,  Disease  of 
the  Epiphysial  Lines,  Excision  of  the  Knee,  Rickets,  and  some  other 
Morbid  Conditions  upon  the  Growth  of  the  Bones.  By  George  Murray 
Humphrey,  M.D. — This  communication,  of  which  an  abstract  is  published 
in  the  number  of  this  Journal  for  July,  1862,  is  intended  as  a  continuation 
of  the  interesting  paper  on  the  growth  of  long  bones  and  of  stumps  in  the 
last  volume  of  Transactions. 

It  is  accompanied  by  two  plates,  containing  eleven  figures,  representing 
several  deformities  and  rickety  bones. 

XYI.  An  Analysis  of  230  Cases  of  Lithotomy.  By  Thomas  Bryant. 
— In  this  paper  Mr.  Bryant  presents  an  analysis  of  all  the  cases  of  lithotomy 
that  could  be  collected  from  the  records  of  G-uy's  Hospital  for  the  last 
twenty-five  years.  Two  hundred  and  thirty  cases  are  thus  brought  together, 
and  tabulated  as  follows  : — 


Age  of  patients 
operated  upon 


2  years , 


Betw'n5&10  yrs. 

"  10  "  15 

"  15  "  20 

"  20  "  30 

"  30  "  40 

"  40  "  50 

"  50  "  60 

"  60  "  70 

"  70  "  80 


2.601 


10.00  | 

10.00  J 
24.34 

13.47 
7.82) 
5.65  } 
3.04^ 
3.04  ~| 
8.26  [ 
2.17  f 
.43j 


73  cases,  or  31*17 
per  cent. 

f  Under  10  yrs. 

J  of  age,  129 
j  cases,  or  56 
t    per  cent. 

38  cases,  or  16  5 
per  cent. 

32  cases,  or  13-9 
per  cent. 


16-66  1  in  6 


Under  10  years 

of  a.ge. 
Med.  T.  &  G. 


— S       —  !  Under  15 
I    of  age. 
4.34  linllf  Jfed.  T.  &  G 
5.34  1  in  l&i|   


6.45 
16.66 
15  38 
14.28 
57.14 
57.89 
60.00 
100.00 


1  inlSij 
lin6  j 
lin6£  i 
I  in  7  ! 
linl£ 


lin  1% 
linl 


Bettveen  15  & 
40  yrs.  of  age. 
Med.  T.  &  G. 

I  Above  40  yrs. 
f    of  age. 
J  Med.  T.  &  G. 


16  1 

21  jl 


1  in  21i 

1  "20 
1  "9f 


The  whole  of  the  cases,  with  five  exceptions,  were  operated  upon  by  the 
lateral  method.  In  four  of  the  five  the  median  operation  was  performed, 
one  of  which  died.    In  one  the  stone  was  extracted  through  the  rectum. 

The  well  recognized  fact  that  calculous  disease  is  more  often  seen  in  early 
life  is  the  first  point  attracting  attention  in  this  table ;  more  than  one-half, 
or  56  per  cent,  of  all  the  cases  having  taken  place  in  children  during  the 
first  ten  years  of  life.  Mr.  Bryant  states,  moreover,  that  the  healthiest 
looking  and  apparently  best  nourished  children  admitted  into  a  London 
hospital  are  those  suffering  with  stone.  According  to  this  statement,  in 
childhood,  stone  in  the  bladder  does  not  appear  to  be  a  disease  of  debility, 
but,  on  the  contrary,  to  belong  to  a  condition  of  body  which  is  not  far  from 
sound  health. 

Another  most  prominent  point  is  the  great  difference  in  the  mortality  of 
the  operation  of  lithotomy  at  the  different  periods  of  life.  The  cause  of 
death  in  the  majority  of  the  fatal  cases  was  clearly  shown  to  have  been 
renal  disease ;  and  it  may  be  safely  asserted  that  from  the  earliest  to  the 
latest  periods  of  life  the  risks  of  lithotomy  are  exactly  commensurate  with 
the  extent  of  the  disease  in  the  renal  organs.  Thus,  in  young  children, 
when  such  disease  is  not  of  frequent  occurrence,  a  good  result,  as  a  rule, 
takes  place ;  but,  at  a  later  period,  when  its  presence  is  more  frequent,  a 


400 


Reviews. 


[April 


bad  result  has  too  commonly  to  be  recorded.  The  best  and  surest  guide 
to  the  diagnosis  of  this  complication  is  the  duration  of  the  symptoms,  and 
in  proportion  to  the  period  of  their  existence  is  the  renal  affection,  as  well 
as  its  extent,  to  be  suspected,  and,  as  a  result,  is  the  danger  of  the  opera- 
tion to  be  dreaded.  The  early  detection  of  a  calculus  becomes,  therefore, 
an  important  point,  and  its  early  removal  a  necessity. 

In  a  postscript  to  this  communication,  Mr.  Bryant  gives  the  following 
table,  for  the  purpose  of  showing  the  apparent  influence  of  chloroform 
upou  the  mortality  of  lithotomy. 


Cases  in  which  chloroform  was  given. 

Cases  in  which  it  was  not. 

Ages. 

ti 

<D 

a 

Percentage. 

u 

Xi 

B 

<v 
u 

Percentage. 

3 

<B 

o 

ft 

% 

P 

P 

5  years  of  age  and  under  . 

40 

38 

2 

31 

30 

1 

3.33  ) 

6  years  and  10  inclusive 

38 

35 

3 

\, 

[.., 

21 

21 

-  3.1 

11        "  15 

19 

18 

1 

5.2 , 

11 

10 

1 

9.09  J 

16        "  20 

10 

7 

3 

30.  i 

8 

8 

21        "  30 

5 

3 

2 

40. 

►  35.2 

8 

8 

31        "  40 

2 

1 

1 

50. 

5 

5 

41   *     "  50 

4 

2 

2 

50.  1 

3 

1 

2 

G6.6Q 

51        "  60 

9 

3 

6 

66. 

-62.5 

10 

5 

5 

50.  ) 

61        "  70 

3 

1 

2 

66. 

2 

1 

1 

50.  1  56.2 

71        "  80 

1 

1 

100.  ) 

130 

108 

22 

16.9 

100 

89 

11 

The  weight  of  evidence  afforded  by  this  table,  taking  the  numbers  as  a 
whole,  apparently  tends  against  the  administration  of  chloroform.  The 
mortality  of  the  operation  of  lithotomy  without  the  use  of  the  anaesthetic 
was  11  percent.,  and  with  it  16.9  per  cent.;  the  difference  between  the 
two  classes  of  cases  was,  therefore,  5.9  per  cent.;  the  use  of  chloroform 
raising  the  mortality  50  per  cent. 

XVII.  On  the  treatment  of  Acute  Rheumatism,  considered  with  regard 
to  the  liability  to  affections  of  the  Heart  under  different  remedies.  By 
W.  H.  Dickinson,  M.  D. — When  it  is  considered  how  large  a  proportion 
of  the  multitudes  who  die  every  year  from  valvular  disease  of  the  heart, 
owe  their  fate  to  the  progressive  mischief  initiated  by  rheumatic  fever,  we 
may  appreciate  the  importance  to  humanity  of  any  discovery  by  which  this 
fatal  alliance  is  prevented.  From  the  multitude  of  facts  which  the  profes- 
sion now  possesses  on  the  subject,  we  believe  that  it  may  safely  be  con- 
cluded that  the  carbonates  of  potassa  and  soda,  with  those  of  their  other 
salts,  which  in  the  body  must  be  presumed  to  be  converted  into  the  car- 
bonates, exert  an  especial  curative  power  over  rheumatic  fever,  and,  if  given 
in  time,  will  completely  protect  the  heart  from  the  dangers  by  which  it  is 
surrounded.  It  is  worth  remarking,  in  connection  with  this  subject,  that, 
contrary  to  what  would  have  been  expected,  no  part  of  the  prohibition 
which  is  afforded  by  full  doses  of  the  alkalies,  or  of  decomposable  salts, 
appears  to  be  afforded  by  quantities  which  fall  short  of  a  certain  definite 
amount.  As  far  as  the  heart  is  concerned,  "partial  alkaline  treatment"  is 
useless. 


1863.]  Medico-Chirurgical  Transactions.  401 


The  following  is  an  abstract  of  Dr.  Dickinson's  tables,  which  include 
164  cases : — 


© 

U  <s  <S 

t  ®— • 

« S.si 

Treatment. 

umb 
of  ca 
>trea 

ases  i 
hich 
beca 
iffect 

^  a  ^  5? 
03  g  e3  eg 

>  2 

Case 
whic 
ende 
fatal 

UP 

1 

Venesection,  with  other  remedies 

8 

4 

41 

0 

2 

6 

2 

29 

0 

3 

7 

1 

27 

0 

— 

Reputed  specifics  (including  guaiacum,  Do- 
ver's powder,  opium,  iodide  of  potassium, 

and  quinine)  

7 

4 

46 

0 

4 

Salines  (less  than  5iij  of  salts  daily  . 

7 

2 

33 

0 

5 

UclllllCO    Willi  ill  11  c 

28 

6 

32 

0 

6 

Salines  with  nitre  and  mercury  . 

7 

1 

36 

1 

7 

Salines  with  mercury  

11 

3 

43 

1 

8 

Salines  with  specifics  

9 

5 

35 

0 

9 

Partial  alkaline  (less  than  ^iv  of  salts  daily) 

8 

3 

28 

0 

10 

Partial  alkaline,  with  other  medicines 

9 

3 

40 

0 

11 

Full  alkaline  (more  than  ^ir  daily)  . 

22 

1 

25 

0 

12 

Full  alkaline,  with  other  medicines 

26 

0 

30 

0 

13 

Salts  of  ammonia  

3 

0 

22 

0 

14 

Incapable  of  classification  .... 

6 

1 

65 

0 

XVIII.  Amaurosis  consequent  on  Acute  Abscess  of  the  Antrum,  pro- 
duced by  a  Carious  Tooth.  By  S.  James  A.  Salter,  M.  B.,  F.  L.  S., 
Surgeon -Dentist  to  Guy's  Hospital. — An  abstract  of  this  communication, 

-  giving  the  details  of  a  very  exceptional  and  important  case,  is  published 
in  the  number  of  this  Journal  for  October,  1862. 

This  paper  is  accompanied  by  a  plate  giving  the  appearance  of  the  peri- 
pheral terminations  of  the  optic  nerves  in  the  retina  of  the  two  eyes,  as 
seen  by  the  ophthalmoscope. 

XIX.  Two  Cases  of  extensive  Arterial  Obstruction  from  separated 
Cardiac  Vegetations,  followed  by  Gangrene  of  the  Lower  Extremities 
and  Death.  By  S.  J.  Goodfellow,  M.  D. — An  abstract  of  this  commu- 
nication is  published  in  the  number  of  this  Journal  for  October,  1862. 
Instances  of  the  plugging  of  arteries  by  so-called  vegetations  from  the 
heart  are  not  uncommon,  but  the  extent  to  which  the  plugging  took  place 
in  these  cases,  the  number  of  vessels  involved,  the  morbid  changes  in  and 
around  the  walls  of  the  vessels  at  the  seat  of  obstruction,  and  the  conse- 
quences which  ensued  give  a  peculiar  interest  to  those  here  recorded  by  Dr. 
Goodfellow. 

This  paper  is  accompanied  by  a  coloured  plate,  representing  the  condi- 
tion of  the  heart  and  bloodvessels,  and  the  spleen  and  kidney. 

XX.  Case  of  Iliac  Aneurism.  By  James  Syme,  F.  R.  S.  E. — An  ab- 
stract of  this  communication  is  published  in  the  number  of  this  Journal  for 
October,  1862.  In  a  postscript,  in  the  volume  before  us,  which  we  will 
transcribe,  we  learn  the  termination  of  this  very  extraordinary  case.  Mr. 
Syme  here  writes  as  follows  : — 

"  This  was  communicated  to  the  Society  only  a  month  after  the  operation,  in 
consequence  of  my  having  occasion  to  be  in  London  at  that  time.  The  favour- 
able anticipations  of  complete  recovery  then  entertained  were  not  realized,  as 
the  general  health,  from  having  been  greatly  impaired,  did  not  improve  in  pro- 
portion to  the  local  progress.  The  patient's  state  seemed  very  precarious  until 
the  end  of  nearly  three  months,  when  so  decided  a  change  for  the  better  took 
No.  XC— April  1863.  26 


402 


Reviews. 


[April 


place  as  to  remove  all  anxiety.  But  soon  after  this,  from  unfortunately  sleeping 
with  an  open  window,  inflammation  of  the  pleura  was  excited,  and  it  proved 
fatal  on  the  31st  of  July.  On  examination  it  was  found  that  the  external  iliac 
had  been  torn  completely  across  and  drawn  up  into  the  pelvis,  where  its  open 
mouth,  being  mistaken  for  a  slit,  had  imposed  upon  the  gentlemen  who  had 
assisted  me,  and  myself,  so  as  to  make  us  suppose  that  the  ligatures  were  ap- 
plied immediately  above  instead  of  below  the  bifurcation  of  the  common  iliac, 
the  whole  extent  of  which  was  imbedded  in  the  sac.  The  true  state  of  matters, 
thus  ascertained,  tends  to  strengthen  the  principle  of  practice  which  it  was  the 
object  of  the  paper  to  maintain." 

XXI.  Contribution  to  the  Statistics  of  Cancer.  By  W.  M.  Baker, 
M.  R.  C.  S.  Communicated  by  James  Paget. — An  abstract  of  this  im- 
portant contribution  to  surgical  statistics  is  published  in  the  number  of  this 
Journal  for  October,  1862.  • 

XXII.  Report  upon  Syphilis,  with  reference  to  the  more  Mixed  and 
Unusual  Forms  of  the  Primary  Symptoms.  By  Jeffrey  A.  Marston, 
M.  D.,  Assistant  Surgeon  of  Royal  Artillery.  Communicated  by  Henry 
Lee,  F.  R.  C.  S. — In  this  paper  the  writer,  who,  as  an  army  medical  officer, 
enjoyed  certain  obvious  advantages  in  his  observations,  speaks  of  syphilis, 
and  with  especial  reference  to  its  more  unusual,  mixed,  and  anomalous 
forms.    The  following  points  are  particularly  treated  of : — 

I.  The  varieties  of  infecting  sore. 
ii.  The  results  of  auto-inoculation. 

in.  The  occurrence  of  syphilitic  infection  after  suppurating  bubo, 
iv.  The  occurrence  of  constitutional  symptoms  following  an  urethral  dis- 
charge clinically  identical  with  gonorrhoea, 
v.  The  bubon  d'emblee. 

vi.  The  periods  of  incubation  preceding  the  appearance  of  the  two  kinds 
of  venereal  sores,  and  the  absence  of  any  proof  that  we  can  guarantee 
against  constitutional  infection  by  any  abortive  treatment  applied  to  the 
primary  syphilitic  lesion. 

On  each  of  these  points  there  is  much  that  is  valuable  in  this  Report. 
Reports  of  cases  made  with  intelligence,  and  under  unusual  facilitating  cir- 
cumstances, and  judged  after  a  thorough  acquaintance  with  the  conclusions 
of  others,  render  it,  in  our  opinion  at  least,  one  of  the  most  remarkable 
papers  that  has  appeared  among  the  many  recent  important  contributions 
to  our  knowledge  of  venereal  disease. 

XXIII.  Case  of  Aneurism  of  the  External  Iliac  and  Common  Femo- 
ral Arteries,  treated  by  Digital  Pressure.  With  Observations.  By  Henry 
Lee. — The  case  of  aneurism  reported  in  this  communication  is  one  of  con- 
siderable interest  in  several  respects ;  but  the  observations  thereupon  are 
not  so  remarkable. 

The  patient,  a  man  31  years  of  age,  experienced  some  pain  in  the  left 
groin  after  a  fall  while  running ;  this  increased,  and  a  swelling,  that 
"jumped,"  made  its  appearance.  At  the  time  Mr.  Lee  saw  him,  or  some 
four  months  after  the  fall,  the  left  thigh  was  much  swollen,  with  some 
marks  of  livid  discoloration  ;  in  the  groin  was  a  tumour  four  inches  in 
diameter,  and  pulsating  strongly.  Continued  digital  pressure  upon  the 
left  external  iliac  artery  was  kept  up  for  some  five  weeks  with  occasional 
interruptions;  the  pain,  the  pulsation,  and  the  thrill  were  at  one  time 
greatly  diminished,  but  afterwards  again  increased.  The  pain  and  swelling 
became  greater,  the  disturbance  of  the  patient's  constitution  was  more 
considerable,  and  four  months  after  he  came  under  Mr.  Lee's  observation 
he  died,  the  limbs  having  become  cold  on  the  previous  day. 


1863.] 


Gairdner,  Clinical  Medicine. 


403 


The  examination  of  the  affected  limb,  which  was  the  only  portion  of  the 
body  that  could  be  examined,  showed  the  following  condition  : — 

"The  superficial  femoral  artery  having  been  exposed,  it  was  traced  to  its 
termination  in  the  common  femoral,  and  this  was  dissected  to  its  termination  in 
the  remains  of  the  sac  of  the  aneurism.  All  the  coats  of  the  artery  were  here 
seen  to  become  suddenly  dilated,  and  after  the  course  of  a  few  inches  to  termi- 
nate in  an  irregular  and  fimbriated  margin.  The  greater  part  of  the  walls  of 
the  aneurismal  cavity  was  formed  by  the  surrounding  structures,  a  complete 
separation  having  taken  place  between  the  upper  and  lower  part  of  the  artery. 
In  the  situation  of  the  aneurism,  when  first  observed,  was  a  very  firm  coagulum 
of  fibrin,  of  an  oval  form.  This  formed  a  sac  complete  in  every  part,  with  the 
exception  of  its  two  extremities,  which  lay  in  the  direction  of  the  natural  course 
'■■  of  the  artery. 

"  The  left  iliac  fossa  contained  a  large  cavity  filled  with  coagulated  blood 
which  extended  nearly  as  high  as  the  umbilicus.  The  body  of  the  pubes,  and 
the  femur  for  several  inches  below  its  lesser  trochanter,  presented  a  rough,  irre- 
gular surface,  from  which  small  particles  of  bone  could  be  detached  with  the 
nail.  All  the  parts  thus  affected  were  in  contact  with  the  blood  effused  from 
the  sac  of  the  aneurism. 

"  The  superficial  femoral  artery  was  found  to  contain  portions  of  decolorized 
fibrin,  which  had  evidently  passed  into  it  from  above.  A  piece  of  this  artery 
was  removed,  and  although  not  presenting  any  marks  of  disease  to  the  naked 
eye,  it  was  torn  across  by  very  moderate  extension  made  with  the  fingers." 

The  complete  separation  that  existed  in  this  case  between  the  upper  and 
lower  portions  of  the  artery  which  formed  the  aneurism,  makes  the  subject 
of  the  kind  of  treatment  suitable  to  the  case  a  very  important  point  for 
consideration,  but  we  see  nothing  to  remark  upon  in  what  is  here  said. 

XXI Y.  Report  of  the  Committee  appointed  by  the  Royal  Medical  and 
Chirurgical  Society  to  investigate  the  subject  of  Suspended  Animation. — 
A  summary  of  this  valuable  report  is  published  in  the  number  of  this  Jour- 
nal for  October,  1862.  W.  F.  A. 


Art.  XVI. —  Clinical  Medicine.  Observations  Recorded  at  the  Bedside, 
with  Commentaries.  By  W.  T.  Gairdner,  Physician  to  the  Royal 
Infirmary  of  Edinburgh,  and  Lecturer  on  the  Practice  of  Medicine. 
Edinburgh:  Edmonson  &  Douglas,  1862.    8vo.  pp.  741. 

This  work  claims  at  the  hands  of  the  reviewer  a  larger  space  than  we 
can  at  present  accord  to  it,  The  author's  previous  contributions  to  medical 
literature  have  secured  for  him  the  reputation  of  an  earnest  worker  in  the 
study  of  disease,  a  close  and  careful  observer,  a  proficient  in  physical  diag- 
nosis, an  acute  reasoner,  and  a  truth-seeker.  At  the  present  moment, 
indeed,  among  those  who  are  devoted  to  ^clinical  medicine,  few,  if  any,  hold 
a  higher  place  in  the  estimation  of  medical  readers  on  this  side  of  the  At- 
lantic than  Dr.  Gairdner.  They  are  fully  prepared  to  receive  with  satisfac- 
tion a  work  from  his  pen  with  the  above  title.  We  should  be  glad  to  give 
the  work  an  extended  analytical  reviewal.  We^should  render  a  service  by 
so  doing  to  the  readers  of  this  Journal  \  but  the  service  will  perhaps  not 
be  less  if  our  brief  notice  may  lead  some  to  read  the  work  who  would  be 
satisfied  with  a  more  comprehensive  examination  of  it  by  the  reviewer. 

The  work  is  made  up  of  various  clinical  lectures,  together  with  a  variety 


404 


Reviews. 


[April 


of  papers  communicated  at  different  times  to  medical  societies.  Several  of 
the  latter  have  already  been  published  in  medical  journals.  The  work  is 
fragmentary,  that  is,  the  diverse  subjects  treated  of  have  no  special  connec- 
tion with  each  other ;  all,  however,  are  subjects  of  interest  and  practical 
importance.  We  must  content  ourselves  with  an  enumeration  of  them, 
and  a  few  annotations  with  reference  to  each. 

1.  Retrospect  of  Cases  treated  during  the  Session  1855-'56. 

The  author  devotes  a  lecture  to  a  summary  of  facts  pertaining  to  the 
histories  and  treatment  of  the  fatal  cases  which  had  been  under  observation 
in  the  Edinburgh  Royal  Infirmary.  The  lecture  will  be  read  with  interest 
by  those  connected  with  large  hospitals,  either  as  students  or  practitioners. 

2.  Remarks  on  the  Treatment  of  Pneumonia,  and  especially  on  the 
Treatment  by  Bloodletting. 

Although  there  are  reasons  why  pneumonia  should  not  be  considered  as 
in  all  respects  the  representative  of  acute  inflammations  generally,  the  pro- 
fession seem  to  have  agreed  to  regard  it  in  this  light.  As  so  regarded,  two 
important  questions  are  at  this  moment  matters  of  controversy.  One  of 
these  questions  is,  has  the  type  of  the  disease  changed  so  that  the  appro- 
priate plan  of  treatment  now  called  for  differs  from  that  which  was  formerly 
efficacious  ?  The  other  question  pertains  to  the  propriety  of  bloodletting  ; 
is  it  ever  called  for,  and  if  so,  under  what  circumstances  ?  With  regard  to 
the  former  of  these  questions,  Dr.  Gairdner  considers  it  to  be  a  question  of 
observation,  and  he  accepts  the  statements  of  his  seniors  who  have  been 
able  fairly  to  compare  the  disease  at  different  remote  periods.  As  regards 
the  second  question,  he  thinks  that  while,  as  a  rule,  the  modern  compara- 
tive disuse  of  bloodletting  is  well  founded,  it  may  be  required  in  excep- 
tional cases.  The  criterion  of  such  cases,  in  his  view,  will  be  the  urgency 
of  the  fever,  pain,  and  dyspnoea,  and  the  general  strength  and  condition 
of  the  patient,  not  the  pathological  condition  of  the  lung,  as  ascertained 
by  physical  diagnosis. 

3.  Five  Years'  Hospital  Experience  of  Pneumonia. 

The  aggregate  number  of  cases  treated  during  these  five  years  is  stated 
to  be  from  60  to  100.  During  this  period,  out  of  ten  or  eleven  fatal  cases 
of  inflammatory  affections  of  the  lungs,  only  one  was  fairly  a  death  from 
idiopathic  or  uncomplicated  pneumonia.  This  result  is  regarded  as  showing 
the  very  slight  tendency  of  pneumonia  per  se  to  a  fatal  result ;  in  other 
words,  death  is  owing  almost  invariably  to  the  coexistence  of  other  affec- 
tions, either  antecedent  or  concomitant.  The  author  states  that  he  has 
adopted  no  routine  method  of  treatment  in  pneumonia.  He  believes  that 
"  what  is  to  be  treated  is  not  so  much  the  pneumonia  as  the  individual 
patient.11  He  attaches  more  value  to  antimony  than  to  any  other  remedy. 
Many  cases  were  treated  with  only  the  common  cough  mixtures.  He  gives 
opium  as  a  palliative.  Mercury  he  employs  very  little.  Stimulants  were 
used  freely  when  the  vital  powers  seemed  in  danger  of  failing.  Food  was 
neither  withheld  nor  pressed. 

4.  On  the  Use  of  Alcoholic  Stimulants  in  Hospital  Medical  Practice. 
This  lecture  is  designed  to  suggest  certain  inquiries  respecting  the  use  of 

alcoholics  in  hospital  practice.  Has  it  not  become  a  custom,  of  late  years, 
to  direct  spirits,  wine,  and  malt  liquors  to  hospital  patients  too  indiscri- 
minately ?  and  is  not  suoh  a  custom  productive  of  harm,  if  not  physically, 
in  a  moral  point  of  view,  by  conducing  to  intemperate  habits  ?  We  fear 
there  is  occasion  for  these  inquiries  in  the  hospitals  of  this  country  as  well 
as  in  Europe.  Dr.  Gairdner  regards  alcoholic  stimulants  as  medicines,  not 


1863.] 


Gairdner,  Clinical  Medicine. 


405 


as  food  after  the  view  of  Dr.  Todd.  The  latter  view,  doubtless,  leads  to 
their  freer  use  than  if  they  are  employed  purely  for  a  remedial  object.  Dr. 
G.  recommends  that  monthly  returns  should  be  made  of  the  amount  of 
alcoholic  liquors  supplied  in  each  ward,  and  an  average  of  the  amount 
given  daily  to  each  patient.  "  By  such  averages,"  he  remarks,  "  physicians 
would  be  invariably  guided  to  the  truth ;  and  the  results  of  various  prac- 
tice would,  when  carefully  compared,  supply  data  hitherto  wanting  for  the 
settlement  of  a  great  many  scientific  questions  connected  with  alcoholic 
stimulants." 

5.  The  Duty  of  the  Physician  with  respect  to  Alcoholic  Stimulants. 
Under  this  head  is  introduced  a  review  of  Professor  Miller's  volume  on 

"  Alcohol ;  its  Place  and  Power."  Dr.  Gairdner's  views  seem  to  us  to  be 
eminently  judicious,  avoiding,  on  the  one  hand,  fanaticism  on  the  subject 
of  temperance,  and,  on  the  other  hand,  recognizing  fully  the  grave  respon- 
sibilities of  the  physician  in  connection  with  this  subject.  He  quotes  the 
remarks  of  James  Jackson  on  the  subject  in  his  "Letters  to  a  Young  Phy- 
sician," as  embodying  fully  his  own  views. 

6.  Influenza. 

In  two  lectures  on  this  subject  he  gives  the  facts  of  an  epidemic  which 
had  recently  occurred.  We  believe  the  author  to  be  correct  in  regarding 
the  disease  as  essentially  a  fever,  of  which  the  catarrh  is  the  local  expression. 
He  cites  the  statistics  contained  in  the  Registrar  General's  Report  of  the 
Mortality  in  London,  as  showing  a  considerable  increase  of  the  death-rate 
in  consequence  of  the  effect  of  the  epidemic  influence  on  different  diseases. 

7.  Distinctions  of  Typhus  and  Enteric  (Typhoid)  Fevers. 

Over  one  hundred  pages  of  the  volume  are  occupied  with  typhus  and 
typhoid  fevers,  including  some  remarks  on  scarlatina.  Dr.  Gairdner  prefers 
Prof.  Wood's  title,  enteric,  to  typhoid  fever.  He  adopts  the  doctrine  of 
the  non-identity  of  this  fever  and  typhus.  Most  of  our  readers,  doubtless, 
will  agree  with  him  in  this  opinion,  albeit  the  identity  of  these  fevers  is 
maintained  by  such  high  authorities  as  Stokes,  Magnus  Huss,  and  others. 
He  gives  some  facts  which  go  to  show  the  origin  of  the  two  fevers  from 
two  distinct  poisons.  He  suggests  the  propriety  of  separating  typhus  and 
typhoid  cases  in  hospitals,  in  order  to  secure  the  latter  from  the  infectious 
miasm  derived  from  the  former.  He  is  of  opinion  that  typhus  has  within 
the  last  few  years  undergone  a  modification  in  its  severity,  being  less  fatal 
than  formerly,  and  also  that  some  of  its  type  features  have  changed. 
We  must  pass  by  this  very  interesting  portion  of  the  work  with  these  few 
notes,  commending  it  to  the  careful  perusal  of  the  reader. 

8.  Pathology  and  Treatment  of  Cholera. 

The  author  gives  concisely  the  morbid  appearances  found  on  the  exami- 
nation of  eighty-nine  fatal  cases  in  the  epidemic  of  1849.  The  examinations 
were  made  in  the  theatre  of  the  Royal  Infirmary  by  Dr.  G.  in  the  course 
of  his  duties  as  pathologist  to  that  institution.  His  general  conclusions 
as  to  the  treatment  are  contained  in  the  following  extract : — 

"  We  are  most  firmly  persuaded  that  cholera,  like  all  other  diseases  dependent 
on  a  specific  poison,  has  a  spontaneous  tendency  to  cure  after  the  virus  has 
exhausted  itself ;  and  that  the  treatment  will  be  most  efficiently  and  successfully 
accomplished  by  discarding,  in  the  majority  of  cases,  heroic  remedies,  by  fol- 
lowing out  the  indications  afforded  by  the  feelings  and  desires  of  the  patient, 
and,  as  Cullen  said,  by  attending  to  those  conditions  and  means  calculated  to 
'  obviate  the  tendency  to  death.'  Now,  all  that  we  yet  know  of  the  pathology 
of  this  disease  tends  to  ascribe  the  fatal  result  in  the  collapse  to  a  slow  asphyxia 
induced  by  the  imperfect  fluidity  of  the  blood.    We  would,  therefore,  endeavour 


406 


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[April 


by  every  means  to  supply  fluid  to  the  blood  through  the  intestines,  the  skin,  the 
lungs,  or  at  least  to  prevent,  in  as  far  as  possible,  the  fluids  of  the  body  from 
being  thrown  off  by  those  channels." 

9.  Syphilis. 

After  a  brief  but  clear  account  of  the  secondary  and  tertiary  symptoms, 
this  lecture  is  occupied  with  an  account  of  several  cases  which  had  pre- 
viously been  made  the  subject  of  bedside  remarks. 

10.  Hysteria;  Delirium  Tremens;  Dipsomania. 

Delirium  tremens  is  regarded  as  a  spontaneously  curable  disorder,  but  is 
to  be  treated  by  remedies  given  in  strict  subordination  to  good  nursing  and 
carefully  adjusted  diet  and  regimen.  Opium,  chloroform,  and  alcoholic 
stimulants  are  useful  if  judiciously  adapted  to  the  indications  in  different 
individual  cases.  In  connection  with  dipsomania  the  author  offers  some 
highly  judicious  remarks  on  what  may  be  called  moral  imbecility.  Here  is 
a  subject  of  great  difficulty,  but  not  less  important  than  difficult  in  its 
medico-legal  relations. 

11.  Pleuritic  Effusion ;  Diagnosis  and  Prognosis;  Question  of  Thora- 
centesis. 

This  subject  occupies  nearly  a  hundred  pages.  The  points  involved  in 
the  diagnosis  are  considered  in  connection  with  several  cases  which  offered 
unusual  features.  In  respect  of  the  prognosis  of  acute  pleurisy,  the  author's 
experience  is  quite  opposed  to  a  statement  contained  in  another  recent 
work.1 

Dr.  G.  states  that,  during  eleven  years  of  hospital  practice,  he  has  met 
with  only  two  cases  of  fatal  acute  pleuritic  effusion.  The  inference  is,  that 
thoracentesis  is  very  rarely  called  for  as  a  measure  to  save  life.  May  it  not 
be  advisable,  however,  both  in  acute  and  chronic  pleurisy,  in  cases  in  which 
the  amount  of  effusion  is  not  sufficient  to  place  life  in  danger  ?  The  author 
is  inclined  to  the  affirmation  to  this  inquiry,  since  he  has  become  acquainted 
with  the  facts  contributed  by  Dr.  Bowditch,  of  Boston,  and  the  means 
employed  by  Dr.  B.  to  withdraw  the  liquid  without  the  introduction  of  air. 

12.  Pneumothorax. 

A  case  is  given  in  which  pneumothorax  from  perforation  ended  in  reco- 
very. Dr.  Gairdner  asserts  that  in  at  least  six  or  seven  cases  he  has  wit- 
nessed phenomena  denoting  cured  pneumothorax.  The  general  impression, 
as  we  suppose,  is  that  this  affection  is  incurable,  and  this  is  certainly  the 
rule.  We  here  met  with  an  instance  in  which  all  the  characteristic  physical 
phenomena  were  unmistakable,  and  the  recovery  was  complete.  In  that 
instance  the  perforation  was  supposed  to  be  n on -tubercular.  But,  if  not 
cured,  pneumothorax  may  continue  indefinitely  and  the  health  of  the  patient 
apparently  be  perfect.  We  communicated  not  long  since  to  the  New  York 
Pathological  Society  a  remarkable  instance  of  this  kind.  In  this  case  the 
perforation  proceeded  from  tubercle,  but  the  latter  affection  was  arrested, 
and  the  patient  was  cut  off  by  an  attack  of  pneumonia.  The  pneumothorax 
was  not  suspected  until  the  attack  of  pneumonia,  but,  from  the  appearances 
after  death,  the  former  affection  must  have  existed  for  a  long  period.  The 
cure  is  effected  by  means  of  the  pleurisy,  the  perforation  becoming  sealed 
up  by  the  pleuritic  adhesions.  Pleurisy  is  thus  both  protected  against  per- 
foration and  a  means  of  cure  when  perforation  occurs. 

13.  Phthisis  Pulmonalis;  Empyema  and  Pneumothorax;  Hydatid  Tu- 
mour of  Lung ;  Emphysema  of  Lungs ;  Remarks  chiefly  on  Physical 
Diagnosis. 

1  Renewal  of  Life.    By  Dr.  Chambers.    Reviewed  in  this  number. 


1863.] 


Gairdner,  Clinical  Medicine. 


407 


These  subjects  occupy  nearly  fifty  pages.  They  are  illustrated  by  cases 
which  are  interesting  and  instructive.  With  respect  to  emphysema  the 
reader  will  be  disappointed  in  not  finding  an  exposition  of  Dr.  Gairdner's 
views  of  the  mechanism  of  this  lesion.  We  regret  this  deficiency  the  more 
because,  with  the  exception  of  a  review  in  the  British  and  Foreign  Medico- 
Chirurgical  Review,  number  for  April,  1853,  his  writings  on  this  subject 
have  not  been  republished  in  this  country,  and  are,  therefore,  not  so  well 
known  as  we  could  desire.  The  chief  point  of  interest  which  is  considered 
in  this  volume  is  the  reality  of  the  auscultatory  sign  described  by  Laennec 
as  pathognomonic  of  emphysema,  viz.,  the,rate  sec  d  grosses  bulles.  This 
sign  has  been  ignored  by  modern  auscultators.  Dr.  Gairdner  thinks  there 
is  such  a  sign,  and  that  Dr.  Laennec's  description  is  correct.  We  must 
confess  that  the  proof  is  not  to  our  mind  altogether  clear. 

14.  Aneurism. 

To  this  subject  over  a  hundred  pages  are  devoted.  It  is  by  no  means 
the  least  valuable  part  of  the  book  ;  for  those  especially  who  are  interested 
in  the  physical  diagnosis  these  pages  will  only  repay  a  careful  perusal. 
The  conclusions  drawn  from  the  study  of  the  cases  which  are  presented  are 
as  follows:— 

"1st.  That  aneurism,  when  accompanied  by  well-marked  angina  pectoris,  is 
probably  situate  in  the  ascending  portion  of  the  arch,  and  near  the  cardiac 
plexus  of  nerves.  The  natural  course  of  such  aneurisms  is  to  burst  into  the 
pericardium,  or  to  compress,  perhaps  open  into,  the  auricles  or  the  pulmonary 
artery,  causing,  in  many  cases,  cyanosis  and  sudden  death." 

"2d.  That  internal  aneurism,  when  attended  by  laryngeal  symptoms,  is  likely 
to  be  so  placed  as  to  involve  the  right  or  the  left  recurrent  nerve,  i.  e.,  either 
in  the  innominate  artery,  or  on  the  posterior  and  inferior  aspect  of  the  arch ;  in 
either  of  which  situations,  but  especially  in  the  latter,  an  aneurism  may  cause 
death  by  laryngeal  suffocation  before  it  is  large  enough  to  be  readily  detected 
by  physical  diagnosis." 

Tracheotomy,  under  these  circumstances,  may  prolong  life,  and  is  war- 
rantable. 

".3d.  That  aneurism,  characterized  chiefly  by  bronchial  asthma  and  ortkopncea, 
is  probably  situate  in  the  commencement  of  the  descending  portion  of  the  arch, 
or,  at  all  events,  so  as  to  compress  the  pulmonary  plexus  of  nerves ;  and  that 
its  consequences  may  be  looked  for  in  the  obstruction  of  one  or  both  bronchia, 
at  first  with  the  symptoms  and  physical  signs  of  asthnratic  bronchitis,  and  after- 
wards of  pneumonia  or  pleurisy." 

"  5th.  That  dysphagia  indicates  pressure  either  on  the  oesophagus,  or  on  the 
pneumogastric  nerve,  and  a  corresponding  situation  of  the  tumour." 

"6th.  That  all  aneurisms  coming  within  the  range  of  physical  diagnosis,  and 
not  attended  by  any  of  these  symptoms,  must  necessarily  arise  either  from  the 
descending  aorta,  below  the  range  of  the  pulmonary  plexus,  or  from  the  upper 
part  of  the  arch,  projecting  upwards  and  forwards ;  as  it  is  in  these  situations 
alone  that  a  thoracic  aneurism  can  attain  sufficient  bulk  to  be  discoverable, 
without  involving  important  internal  structures,  and  leading  to  very  marked 
functional  disturbance." 

Dr.  G.  bears  testimony  to  irregularity  of  the  pupils  as  one  of  the  signs 
of  an  aneurismal  tumour  pressing  on  the  sympathetic  nerve. 

15.  Cardiac  Murmurs. 

The  sixty-six  pages  occupied  with  this  subject  form  a  very  valuable  por- 
tion of  the  work.  The  inadequateness  of  murmurs  alone  as  signs  of  grave 
lesions  is  enforced  and  exemplified  by  a  series  of  cases.  The  distinctive 
characters  of  the  aortic  and  mitral  murmurs  are  clearly  described  and  made 
still  clearer  by  means  of  diagrams ;  so  also  of  pulmonic  and  tricuspid  mur- 


408 


Reviews. 


[April 


murs.  The  latter  (i.  e.  tricuspid),  Dr.  Gr.  thinks,  are  much  more  frequent 
than  is  generally  supposed;  they  are  not  infrequently  confounded  with 
mitral  murmurs.  We  commend  this  portion  of  the  work  to  those  engaged 
in  the  delightful  study  of  cardiac  auscultation. 

16.  Retrospect  of  200  Cases  under  Treatment  in  the  Royal  Infirmary, 
during  the  Winter  Session  1859-'60. 

This,  with  a  concluding  lecture  on  the  "Study  of  Clinical  Medicine," 
occupies  the  last  eighty  pages  of  the  work. 

We  repeat  that,  had  time  and  space  permitted,  we  should  gladly  have 
engaged  in  an  extended  analytical  review  of  this  work.  We  consider  it  to 
be  a  very  valuable  contribution  to  the  literature  of  practical  medicine.  The 
cases  which  are  given  were  recorded  either  by  the  author  or  under  his  dicta- 
tion ;  and  we  agree  with  him  entirely  in  the  opinion  that  this  is  necessary, 
in  order  that  the  clinical  teacher  may  become  thoroughly  conversant  with 
the  cases  which  he  undertakes  to  study  for  the  benefit  of  his  pupils  as  well 
as  for  his  own  improvement.  It  seems  to  be  a  common  impression  that 
any  young  physician  or  an  advanced  student  is,  at  once,  as  a  matter  of 
course,  competent  to  record  cases ;  but  the  truth  is,  it  is  an  art  to  be  ac- 
quired by  practice,  requiring  not  only  a  certain  amount  of  knowledge,  but 
an  aptitude  for  observation  and  description  which  is  to  be  corrected  and 
improved  by  discipline,  and  which  some  can  never  acquire.  To  exercise 
the  senses  intelligently  and  accurately,  to  observe  and  reason  without  pre- 
conviction or  bias,  to  describe  literally  and  truthfully — these  are  accom- 
plishments by  no  means  so  general  or  so  easily  acquired  as  many  seem  to 
suppose.  As  evidence  of  this,  how  few  of  the  many  contributions  to 
clinical  medicine  command  or  deserve  entire  confidence  I 

Of  Dr.  Gairdner  as  a  clinical  teacher  we  have  already  spoken.  We  have 
in  this  volume  his  bedside  teachings,  divested,  it  is  true,  of  the  interest  and 
force  derived  from  witnessing  the  cases  and  listening  to  his  voice,  but,  as 
some  compensation  for  this  loss,  perhaps  expressed  with  more  precision 
than  is  to  be  expected  in  an  oral  discourse.  As  an  American,  it  is  refresh- 
ing to  find  in  the  volume  frequent  references  to  his  co-labourers  on  this  side 
of  the  Atlantic.  The  names  of  Jackson,  Ware,  Bowditch,  and  others,  are 
repeatedly  mentioned.  Aside  from  the  practical  information  which  the 
volume  contains,  its  tone  is  well  suited  to  promote,  in  the  minds  of  those 
entering  upon  clinical  study,  the  spirit  of  a  true  philosophy. 


Art.  XVII. — A  System  of  Surgery,  Tlieoretical  and  Practical,  in  Trea- 
tises by  various  Authors.  Edited  by  T.  Holmes,  M.  A.,  Cantab.,  &c. 
&c.  In  four  vols.  Yol.  III.  London,  Parker  Son  and  Brown.  1862. 
8vo.  pp.  916. 

The  third  volume  of  this  authoritative  publication  has  been  for  some 
months  upon  our  table,  having  made  its  appearance  in  excellent  time  for  an 
enterprise  of  its  peculiar  character,  and  considering  the  number  and  occupa- 
tion of  the  parties  engaged  upon  it.  They  and  their  industrious  editor  have 
done  so  well  in  their  progress  that  we  may  look  forward  with  confidence  to 
an  early  fulfilment  of  the  promise  of  the  preface  in  the  appearance  of  the 


1863.] 


Holmes,  A  System  of  Surgery. 


409 


concluding  volume,  with  the  index,  which  is  to  render  the  whole  at  once  a 
most  convenient  and  complete  text  book  on  hospital  surgery. 

The  present  volume  at  least  equals  its  predecessors  in  practical  interest 
and  value,  both  as  to  subjects  and  the  mode  of  treating  them.  Indeed 
we  are  tempted  to  regard  it  as  superior  fh  some  respects.  The  circle  of 
authors  extends  beyond  the  officers,  mostly  junior,  of  the  London  hospitals, 
and  thus  includes  more  weight  and  less  merely  local  character;  many  of  the 
subjects  involve  the  most  important  and  freshly  mooted  questions  in  sur- 
gery ;  and  all  appear  to  be  considered  not  only  with  practical  skill  and 
experience,  but  with  a  careful  and  generally  intelligent  reference  to  the 
labours  of  the  latest  authorities  of  this  country,  as  well  as  of  Europe. 
These  constant  references  are  invaluable  by  enabling  the  reader  to  follow 
out  his  author  in  his  whole  course  of  inquiry,  and  thus  add  much  of  the 
eclectic  usefulness  of  an  encyclopedia  to  the  more  direct  availability  of  the 
work  as  a  clinical  guide. 

There  is  not  much  to  be  said  in  favour  of  the  order  of  arrangement  as 
thus  far  exhibited.  Iff  this  respect  the  editorial  offspring  of  Mr.  Holmes 
must  share  the  lot  of  many  other  valuable  productions  of  his  British  brethren. 
His  system  is  rather  a  collection  of  essays  developed  and  brought  together 
with  a  common  object,  but  very  much  at  the  convenience  of  the  authors, 
yet  under  the  rule  of  a  director  who,  doubtless,  intends  to  reconcile  all  con- 
fusion and  to  avoid  the  trouble  which  no  classification  will  prevent,  by  the 
ample  index  which  he  has  announced  as  in  course  of  preparation. 

The  papers  of  this  volume  are  on  operative  surgery,  on  the  diseases 
of  the  organs  of  special  sense  (excepting  the  eye,  already  published),  of 
the  air-passages,  and  of  the  organs  of  circulation,  locomotion,  and  innerva- 
tion. Lastly,  diseases  of  the  organs  of  digestion  are  commenced,  by  a 
treatise  on  the  affections  of  the  tongue. 

In  regard  to  operative  surgery,  a  regular  treatise  would  have  led  to 
constant  repetition  of  other  portions  of  the  work,  and  is  therefore  not 
attempted.  The  section  is  limited  to  a  chapter  on  minor  surgery,  one  on 
amputations,  another  on  anaesthesia,  and  a  fourth  on  plastic  surgery,  illus- 
trated by  the  description  of  such  operations  as  could  be  conveniently  sepa- 
rated from  the  sketches  of  the  lesions  for  which  they  are  practised. 

The  article  on  minor  surgery  is  brief  but  practical,  and  sufficiently  com- 
prehensive for  a  series  which  includes  the  consideration  of  minor  surgery 
topics  under  various  other  heads. 

Bandages  and  their  applications  are  disposed  of  in  the  first  eight  pages. 
Then  come  the  immovable  apparatus,  in  various  forms  of  plastic  dressings, 
for  fractures  and  articular  affections ;  sutures  and  their  application  ;  counter- 
irritation  ;  acupuncture ;  electro -puncture ;  hypodermic  and  endermic  medi- 
cation ;  issues  ;  setons  ;  blood-letting ;  vaccination  ;  caustics ;  and,  finally, 
the  strangulation  of  naevi  and  other  tumours. 

Perhaps  the  most  interesting  portion  of  this  chapter  is  that  on  sutures. 
It  might  have  been  still  more  explicit  with  advantage,  and  yet  is  up  to  the 
times  on  the  use  of  silver  and  iron  wire.  The  author  is  not  very  clear  in 
his  account  of  the  introduction  of  the  metallic  suture  into  general  practice. 
Dr.  Simpson  is  mentioned,  without  a  date,  as  the  first  to  draw  attention  to 
the  subject  in  his  country,  and  Dr.  Sims  is  then  named  as  the  first  to  make 
the  application  in  America,  "in  1849."  The  author  cites  the  Anniversary 
Discourse,  before  the  N.  Y.  Academy  of  Medicine,  for  1858,  by  Dr.  Sims, 
"On  Silver  Sutures  in  Surgery,"  without  considering  that  this  discourse 
preceded  the  paper  of  Dr.  Simpson,  and  may  have  prompted  the  investi- 


410 


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[April 


gations  reported  in  that  paper.  He  also  quotes  the  passage  from  Fabricius 
ab  Aquapendente,  in  which  the  wire  suture  was  recommended  two  centuries 
ago;  and  refers  to  a  report  in  the  London  Lancet,  Nov.  29,  1834,  which 
shows  that  Mr.  Gossett  successfully  treated  a  case  of  vesico-vaginal  fistula 
by  silver-gilt  wire  sutures,  fifteen*  years  in  advance  of  Dr.  Sims.  He  should 
have  referred  to  the  experiments  of  Levert  in  America  (see  this  Journal 
for  May,  1829),  and  the  cases  of  Dieffenbach  in  Germany,  and  of  Mettauer 
in  this  country  (see  this  Journal  for  Nov.  1833  and  Feb.  1838),  to  show 
that  the  metallic  substitute  was  known  and  appreciated  in  modern  practice 
on  both  sides  of  the  Atlantic,  before  the  date  of  Mr.  Gossett's  publication. 
Heister,  too,  as  well  as  Fabricius,  could  be  quoted  to  prove  that  the  idea 
of  the  wire  is  by  no  means  a  recent  one  in  surgery.  Still,  Dr.  Sims  is  enti- 
tled to  the  merit  of  its  final  introduction  into  practice,  and  deserves  the 
principal  share  of  the  thankful  acknowledgment  which  is  given  in  this  article 
to  Dr.  Simpson. 

The  author  agrees  with  Dr.  Sims  in  preferring  the  silver  to  the  iron  wire. 
A  considerable  experience  with  both  materials,  ancf  especially  with  iron, 
inclines  us  to  coincide  entirely  with  Dr.  Simpson  in  being  content  with 
well  annealed  iron  wire  as  quite  equal  to  silver ;  but  a  still  larger  experience 
with  lead  wire  has  convinced  us  that  it  is  more  desirable  than  either  silver 
or  iron  in  the  great  majority  of  cases,  on  account  of  its  greater  cheapness 
than  silver,  and  its  superior  pliability.  The  only  objection  to  the  lead  is 
its  want  of  strength  in  case  of  strain;  though,  in  some  instances,  this  is  a 
positive  advantage. 

The  next  two  essays  are  on  amputations  and  ansesthetics.  Their  author, 
Mr.  Joseph  Lister,  Prof,  of  Surgery  in  the  University  of  Glasgow,  has  given 
two  papers,  which  are  excellent,  theoretically,  practically,  and  historically; 
each  one  being  so  good  a  resume,  in  fact,  that  we  should  be  glad  to  see 
them  published  together  by  their  author,  separately  from  the  "system," 
like  the  tract  on  gunshot  wounds,  by  Longmore.  With  some  additions 
and  illustrations  they  would  make  a  very  desirable  companion  to  that 
admirable  little  book,  for  the  army  surgeons  of  both  countries. 

There  are  certainly  no  subjects  upon  which  the  surgeons  of  America  are, 
and  for  two  years  past  have  been,  more  keenly  alive  than  these  two  of 
amputations  and  anaesthetics.  A  vast  deal  of  individual  experience,  of 
course,  has  been  acquired,  and  must  continue  to  accumulate  upon  the 
various  practical  questions  which  were  still  more  or  less  unsettled  on 
these  points  among  sensible  practitioners  at  the  outbreak  of  our  civil  war. 
But,  until  the  master  records  of  this  experience  have  reached  us,  in  some 
tolerably  digested  form,  we  know  of  nothing  that  would  attract  a  closer 
practical  attention,  or  receive  a  more  effectively  useful  sifting  than  a  sum- 
mary like  this  of  Professor  Lister's,  which  is  so  evidently  the  work  of  an 
accomplished  clinical  teacher  and  hospital  operator,  and  so  free  from  the 
merely  mechanical  routine  of  the  dissecting  room.  Our  younger  army 
surgeons  may  safely  adopt  Mr.  Lister's  general  principles  of  operating 
and  dressing ;  and  even  those  who  begin  to  feel  like  veterans  with  the 
amputating  knife  and  in  the  hospital,  may  study  his  pages  with  immediate 
advantage  to  their  labours,  and  with  probably  still  greater  benefit  to  the 
final  establishment  of  their  own  conclusions.  We  regret,  therefore,  our 
inability  to  dwell  upon  many  matters  which  have  struck  us  as  quite  worthy 
of  special  consideration;  and  we  sincerely  hope  that  the  author  may  allow 
the  separate  circulation  of  both  papers,  in  such  a  shape  as  will  bring  them 
within  reach  of  the  hundreds  who  could  soon  test  their  precepts  in  the  field. 


1863.] 


Holmes,  A  System  of  Surgery. 


411 


The  article  on  anaesthetics  is  short,  but  clear  and  practical,  at  least  in 
regard  to  chloroform.  Yery  little  is  said  about  ether,  except  that  it  is 
considered  less  potent  and  more  irritating,  less  agreeable  in  odour,  more 
volatile,  and  more  inflammable  than  chloroform  ;  and  that  it  has  therefore 
been  generally  superseded  by  the  latter  in  Europe,  although  still  extensively 
used  in  America.  Both  agents  have  been  so  largely  employed  by  intelli- 
gent operators  in  the  recent  campaigns  of  our  armies,  that  some  definite 
comparison  must  by  this  time  have  been  put  on  record,  which  may  here- 
after determine  the  real  superiority,  for  availability  and  pleasant  action,  of 
chloroform  to  ether,  and  its  approximately  or  entirely  equal  safety  under 
proper  management.  It  is  to  be  hoped  that  some  of  our  army  surgeons 
have  at  last  discovered  the  most  effective  and  economical  mode  of  safely 
using  both  ether  and  chloroform  for  anaesthetic  purposes.  They  have  pro- 
bably become  convinced  that  the  danger  to  life,  which  amounts  to  nothing, 
without  gross  carelessness,  in  the  employment  of  ether,  is  not  seriously  in- 
creased in  the  resort  to  chloroform,  and  may  be  prevented  almost  wholly 
by  sufficient  care  in  the  use  of  either  of  these  two  anaesthetics.  They  must 
be  satisfied  also,  by  this  time,  that  great  prostration  from  shock  or  other 
causes  is  or  is  not  a  contra-indication  for  anaesthetic  action ;  and  they  ought 
to  be  able  to  tell  us  whether,  in  case  of  such  prostration,  ether  or  chloro- 
form is  the  preferable  agent. 

Prof.  Lister  expresses  strong  doubts  of  the  injurious  agency  of  chloro- 
form in  some  of  the  alleged  cases  of  fatal  inhalation.  Nor  does  he  agree 
that  the  danger  is  any  greater  in  disease  of  the  heart.  He  is  more  inclined 
to  attribute  a  positively  sustaining  power  to  the  chloroform  anaesthesia,  which 
enables  patients  to  survive  under  depressing  influences  that  might  other- 
wise destroy  them.  This  view  of  the  action  «f  chloroform  leads  him  to 
regard  it  as  an  important  agent  to  be  relied  upon  in  averting  the  danger 
of  prostration  from  injury,  and,  as  therefore  aiding  very  materially  in  the 
performance  of  operations  before  reaction  has  commenced.  We  believe 
this  position  to  be  in  accordance  with  the  civil  and  military  experience  of 
this  country,  as  well  as  of  Europe,  and  are  disposed  to  regard  it  as  appli- 
cable to  ether  no  less  than  chloroform,  at  least  in  hospital  practice.  What 
may  be  the  rule,  as  determined  in  the  field,  we  have  not  learned  from  actual 
experience.  Chloroform,  however,  is  so  much  more  convenient  for  carrying 
purposes,  that  the  question  between  it  and  ether,  in  the  field,  may  be  of  com- 
paratively little  practical  moment.  If  ether  can  be  transported  without  loss 
from  evaporation  as  securely  as  chloroform,  and  can  be  made  to  produce 
its  anaesthetic  effects  as  promptly  and  with  as  small  a  consumption  of  the 
supply,  which  is  necessarily  limited  on  such  occasions,  then  the  certain  dif- 
ference in  favour  of  the  ether  as  to  safety,  at  least  with  careless  operators, 
would  justify,  if  not  demand,  its  preference  to  chloroform.  We  hope  to 
see  the  administration  of  ether  shown  to  be,  in  proper  hands,  as  prompt 
and  economical  in  its  action  as  chloroform,  although  there  is  no  prospect 
of  its  becoming  less  likely  to  evaporate  or  burn  ;  and  we  shall  expect  that 
its  use  as  an  anaesthetic  will  rather  be  increased  than  diminished  in  civil  life, 
by  the  observations  of  those  who  are  now  watching  its  modus  operandi  in 
the  military  hospitals  and  fields  of  this  country. 

It  is  the  overdose  of  chloroform,  or  its  too  long  continuance,  that,  in 
Mr.  Lister's  opinion,  is  the  most  frequent  cause  of  death.  In  this  he  is 
on  the  side  of  the  majority  of  those  who  have  studied  the  vital  question 
both  as  to  ether  and  chloroform ;  and  touches  at  once  upon  the  leading 
practical  point  of  the  whole  inquiry.    Stertor  and  obstructed  respiration 


412  Reviews.  [April 

are  the  alarming  signs  which  the  surgeon  must  attend  to  with  the  greatest 
care. 

"  The  most  convenient  test  of  the  patient  being  prepared  for  undergoing  the 
operation  is  presented  by  the  eye  ;  not  in  the  size  of  the  pupil,  which  is  incon- 
stant in  its  indications,  but  in  what  is  commonly  spoken  of  as  insensibility  of  the 
conjunctiva ;  though  in  truth  it  has  no  relation  to  sensation,  which  is  abolished 
considerably  earlier;  but  when  unconscious  winking  no  longer  occurs,  on  the 
eyeball  being  touched  with  the  tip  of  the  finger,  we  have  a  good  criterion  of  the 
suspension  of  reflex  action  in  the  body  generally.  At  this  period  the  pulse  is 
about  in  a  normal  condition,  and  the  respiration  is  usually  either  natural  or  very 
slightly  stertorous,  though  persons  with  a  tendency  to  swoon  may  do  so  almost 
from  the  commencement  of  inhalation.  But  if  the  administration  of  the  chloro- 
form be  further  persisted  in,  strongly  stertorous  breathing  will  soon  be  induced, 
and  will  become  aggravated  until  it  passes  into  complete  obstruction  to  the 
entrance  of  air  into  the  chest,  though  the  respiratory  movements  of  the  thoracic 
walls  still  continue.  Occasionally,  however,  the  premonitory  stertor  is  deficient, 
and  the  breathing  more  or  less  suddenly  obstructed.  This  is  a  point  of  great 
importance  ;  for,  without  close  attention,  it  may  escape  notice,  when  the  patient 
will  be  placed  in  imminent  peril.  For,  though  the  respiration  may  be  resumed 
spontaneously,  this  cannot  be  relied  on,  and  it  would  seem  that  when  chloroform 
is  given  in  an  overdose,  the  cardiac  ganglia  are  apt  to  become  enfeebled ;  and, 
on  this  account,  asphyxia  produces  more  rapidly  fatal  effects  than  under  ordi- 
nary circumstances.  But  if  the  obstructed  state  of  the  breathing  is  noticed  as 
soon  as  it  occurs,  and  the  cloth  is  immediately  removed  from  the  face,  and  the 
tip  of  the  tongue  seized  with  a  pair  of  artery  forceps  and  drawn  firmly  forwards, 
the  respiration  at  once  proceeds  with  perfect  freedom,  the  incipient  lividity  of 
the  face  is  dispelled,  and  all  is  well."  (pp.  100-1.) 

Prof.  Lister  is  "  anxious  to  direct  particular  attention  to  the  drawing 
out  of  the  tongue,  because  Lam  satisfied  that  several  lives  have  been  sacri- 
ficed for  want  of  it."  The  traction  should  be  decided,  however,  or  it  may 
fail.  We  have  been  very  much  impressed  with  the  effect  of  this  expedient 
on  two  different  occasions — one  of  imminent  death  under  chloroform,  and 
the  other  of  a  similar  state  of  things  occurring  to  a  patient  who  was  sup- 
posed to  be  inhaling  ether.  In  each  case  respiration  had  ceased  for  a 
moment,  and  the  countenance  had  become  rigid,  when  we  threw  the  patient's 
head  over  the  edge  of  the  bed  with  one  hand,  and,  with  the  other,  seized 
the  tongue  and  forcibly  drew  it  out  as  far  as  possible.  The  air  rushed  in 
with  a  peculiar  sound,  the  patient  heaved  a  sigh,  and  again  began  to  breathe. 
In  the  chloroform  case  there  had  been  no  mechanical  interference  with  the 
respiration  on  the  part  of  the  assistant  who  held  the  folded  napkin.  In 
the  ether  case,  the  patient  was  deliberately  suffocated  through  the  careless- 
ness of  the  assistant,  the  ether  being  inhaled  from  a  cup-shaped  sponge  in 
a  stiff  and  entirely  close  pasteboard  cone,  which  was  so  firmly  pressed  upon 
the  face  as  not  to  allow  any  air  whatever  to  mingle  with  the  anaesthetic. 
The  hand,  with  its  fingers,  is  the  best  instrument  to  employ  for  this  traction 
of  the  tongue,  because  it  is  always  ready  and  leaves  no  mark  behind. 

Our  author  gives  a  very  interesting  account  of  some  investigations,  made 
with  great  care  upon  himself,  in  regard  to  the  nature  of  the  stertor  and  the 
rationale  of  the  traction  of  the  tongue  in  stopping  it,  which  satisfied  him 
that  the  pulling  out  of  the  tongue  does  not  act  merely  mechanically,  but 
through  the  nervous  system  by  a  kind  of  reflex  operation.  He  found  that, 
besides  the  palatine  snoring,  there  is  another  form 

"which  is  the  profound  stertor  essentially  concerned  with  chloroform,  depends 
on  a  cause  seated  further  down  the  throat,  and,  for  reasons  to  be  given  imme- 
diately, may  be  termed  laryngeal.    By  digital  examination  of  my  own  throat,  I 


1863.]  Holmes,  A  System  of  Surgery.  413 

found  that  the  latter  variety,  and  the  complete  obstruction  into  which  it  passes, 
could  still  be  produced  when  the  tongue  was  separated  by  a  considerable  inter- 
val from  the  back  of  the  pharynx,  while  a  free  passage  to  the  air  existed  on- 
wards to  the  lips,  which  showed  that  the  general  belief  that  the  obstruction 
depends  on  a  '  falling  back  of  the  tongue'  is  erroneous.  Also  the  epiglottis, 
instead  of  being  folded  back  during  the  obstruction,  as  some  have  supposed, 
had  its  anterior  edge  directed  forwards  ;  and  though  it  was  thrown  into  vibra- 
tions when  the  stertor  was  strongest,  it  was  evident  that  the  cause  of  the  sound 
was  more  deeply  placed.  I  also  found  that,  although  firm  traction  upon  the 
tongue  abolished  the  obstruction  and  the  stertor,  it  did  not  appear  to  produce 
the  slightest  change  in  the  position  of  the  base  of  the  tongue;  nor  did  it  move 
the  os  hyoides  upon  the  thyroid  cartilage,  as  examined  from  without.  Hence 
I  was  led  to  conclude  that  the  beneficial  effect  of  this  procedure  could  not  be 
explained  mechanically,  but  must  be  developed  in  a  reflex  manner  through  the 
medium  of  the  nervous  system."  (p.  102.) 

He  goes  on  to  describe  his  observations  on  his  own  vocal  apparatus  with 
the  laryngoscope.    He  then  ascertained  that 

"The  true  laryngeal  stertor  results  from  the  vibration  of  the  portions  of  mu- 
cous membrane  surmounting  the  apices  of  the  arytenoid  cartilages,  i.  e.,  the 
posterior  parts  of  the  aryteno-epiglottidean  folds  (thick  and  pulpy  in  the  dead 
body,  but  much  more  so  when  their  vessels  are  full  of  blood),  which  are  carried 
forwards  to  touch  the  base  of  the  epiglottis  during  the  stertorous  breathing,  and 
are  placed  in  still  closer  apposition  with  it  when  the  obstruction  becomes  com- 
plete. Having  one  hand  at  liberty,  I  was  able  to  observe  the  effect  of  drawing 
forward  the  tongue  under  these  circumstances,  and  saw  that  firm  traction 
induced  the  obstructing  portions  of  mucous  membrane  in  contact  with  the  epi- 
glottis, to  retire  from  it  for  about  an  eighth  of  an  inch,  so  as  to  allow  free  pas- 
sage for  the  air,  while  the  epiglottis  itself  was  not  moved  forwards  in  the  slightest 
degree."  (pp.  102-3.) 

We  are  unable  to  give  more  space  to  this  interesting  paper  except  to 
note  that  he  continues  to  urge  a  close  watching  of  the  respiration  as  all- 
important,  and  a  disregard  of  the  pulse  as  immaterial  and  likely  to  lead 
astray,  and  that  he  gives  chloroform  without  hesitation  in  cases  of  heart 
disease ;  quoting,  in  support  of  these  precepts,  his  own  eight  years'  expe- 
rience, and  the  authority  of  Mr.  Syme,  who  has  long  observed  and  taught 
them  without  having  lost  a  patient  in  about  five  thousand  trials. 

Plastic  surgery  is  the  subject  of  the  article  next  in  order,  by  Mr.  Holmes 
Coote.  Beginning  with  a  short  historical  sketch  of  the  rise  of  Taliacotian 
operations  under  the  auspices  of  the  famous  professor  of  Bologna,  Mr.  Coote, 
occupies  some  seven  pages  with  an  instructive  review  of  the  general  prin- 
ciples of  plastic  surgery.  In  the  course  of  this  he  takes  care  to  make  the 
right  acknowledgment  to  Dr.  Marion  Sims  for  "his  energetic  advocacy"  of 
the  use  of  metallic  sutures,  and  for  their  consequent  introduction  into  prac- 
tice, especially  in  plastic  operations.  Rhinoplasty  and  cheiloplasty  are  fully 
discussed,  including  the  restoration  of  the  nose,  hair-lip,  lower  lip  and 
upper  lip ;  also  plastic  operations  on  the  ear,  on  the  penis,  the  management 
of  adherent  and  contracted  vagina,  and  of  cicatrices  from  burns  and  escha- 
rotics.  The  directions  are  ample  and  easily  understood,  with  the  assistance 
of  illustrations  in  some  instances,  and  contain  many  very  useful  hints  for 
the  guidance  of  inexperienced  practitioners.  His  advice  on  the  treatment 
of  contracted  cicatrices  is  especially  worthy  of  recollection  ;  it  is  that  "no 
cutting  instrument  should  be  used."  Again,  "It  maybe  laid  down  as  a 
rule,  almost  without  exception,  that  a  cicatrix  should  never  be  touched 
with  a  knife."  He  tells  us  that  these  operations  have  for  some  time  past 
been  discarded  as  useless  at  St.  Bartholomew's  and  some  other  leading  hos- 


414 


Reviews 


[April 


pitals  of  London.  The  best  that  can  be  done  is,  with  gradual  dilatation, 
extension  and  pressure,  aided  by  the  application  of  unguents,  to  stimulate 
the  removal,  by  absorbent  action,  of  the  contracting  tissue.  The  results 
of  this  treatment,  he  assures  us,  "are  mostly  satisfactory,  and  failure  pro- 
ceeds from  want  of  patience,  which  substitutes  forcible,  and,  as  it  were, 
spasmodic  efforts,  for  persevering  and  unremitting  gentleness." 

Under  the  head  of  "Diseases  of  the  Organs  of  Special  Sense,"  Mr. 
James  Hinton  contributes  a  carefully  prepared  and  practical  chapter  on 
"  Diseases  of  the  Ear,"  and  Mr.  Ure  a  well  arranged  one  on  "Diseases  of 
the  Nose,"  which  is  equally  practical  in  character. 

The  next  paper,  on  "Diseases  of  the  Larynx,"  was  the  unfinished  work 
of  the  late  Mr.  Henry  Gray,  whose  sudden  death  prevented  its  final  revision 
by  the  author.  The  disorders  treated  of  are  acute  laryngitis,  oedema  of  the 
glottis,  erysipelatous  laryngitis,  diffuse  inflammation  of  the  cellular  tissue 
of  the  larynx,  syphilitic  ulceration  of  the  larynx,  tumours  of  the  larynx 
and  trachea,  hysterical  affections  of  the  larynx,  spasm  of  the  glottis,  chronic 
laryngitis ;  the  same  with  ulceration,  and  with  affections  of  the  laryngeal 
cartilages  as  the  result  of  the  inflammation.  Mr.  Gray's  chapter  is  fol- 
lowed by  a  supplementary  one  on  the  "Laryngoscope,"  by  Mr.  A.  S.  Dur- 
ham, which  was  rendered  necessary  by  the  fragmentary  condition  in  which 
the  notes  on  this  subject  were  left  by  their  lamented  author.  Mr.  Durham's 
short  account  of  this  new  instrument  and  its  applications  appears  to  be 
sufficient,  historically  and  practically,  to  afford  an  efficient  introduction  to 
its  use,  and  to  show  its  really  great  value  in  the  chronic  disorders  of  the 
larynx  and  all  the  obscure  affections  of  this  organ.  Mr.  Durham  is  not 
very  decided  as  to  the  general  utility  of  the  laryngoscope ;  but  while  ready 
to  admit  that  it  may  remain  in  the  hands  of  the  few,  he  is  yet  convinced 
that  it  is  destined  to  do  much  good  to  the  many.  In  this  respect  it  does 
not  differ  from  the  most  of  its  predecessors  in  the  march  of  improvement ; 
and  it  will  not  be  allowed  to  remain  in  obscurity  merely  on  account  of  the 
ignorance  and  indolence  which  obstruct  the  progress  of  every  new  instru- 
ment where  the  necessary  skill  in  manipulation  and  observation  are  only  to 
be  acquired  by  special  and  laborious  exercise. 

The  next  grand  division  is  devoted  to  diseases- of  the  organs  of  the  circula- 
tion, and  begins  with  a  chapter  by  Mr.  C.  H.  Moore,  surgeon  to  Middlesex 
Hospital,  on  the  "Diseases  of  the  Absorbent  System."  Wounds  of  lympha- 
tics, inflammation  of  lymphatics  (angeioleucitis),  inflammation  of  lymphatic 
glands  (adenitis),  hypertrophy  and  atrophy  of  glands,  strumous  disease  of 
glands,  lymphatics  in  syphilis,  gonorrhoea,  cancer,  in  indolent  diseases — 
including  ulceration,  erysipelas  and  naevi,  morbid  contents  of  lymphatics, 
obstruction,  obliteration  and  varicosity  of  lymphatics,  excision  of  glands 
by  operation — are  severally  discussed  with  care  and  ample  fulness  where 
they  are  not  considered  in  other  parts  of  the  work.  Strumous,  syphilitic, 
gonorrhoeal,  and  cancerous  disease  of  the  glands,  for  instance,  are  but 
slightly  touched  upon,  as  they  are  sufficiently  studied  in  the  articles  on  their 
several  forms  of  general  disorder.  Other  special  affections  of  the  lymphatic 
system  receive  a  close  practical  consideration  in  regard  to  their  pathology 
and  local  and  general  treatment. 

Next  in  order  comes  the  section  on  "Diseases  of  the  Veins,"  by  Mr.  G. 
W.  Callender,  Assistant-Surgeon  to  St.  Bartholomew's  Hospital.  The 
first  topic  is  adhesive  phlebitis,  or  inflammation  of  the  lining  membrane  of 
the  veins,  which  Mr.  Callender  agrees  with  the  more  recent  pathologists  in 
regarding  as  of  "  more  than  doubtful  occurrence."    He  compares  the  views 


1863.] 


Holmes,  A  System  of  Surgery. 


415 


of  John  Hunter,  Meckel,  Gendrin,  and  others,  with  those  of  Guthrie, 
Travers,  Lee,  and  others,  in  opposition  to  them  ;  and,  after  referring  to 
the  experimental  demonstration  by  Lee  of  the  fallacy  of  Genclrin's  experi- 
ments as  to  plastic  deposits  in  irritated  veins  when  really  deprived  of  blood, 
the  author  shows  conclusively,  by  a  repetition  and  extension  of  Mr.  Lee's 
experiments,  that  in  the  lower  animals,  at  least,  the  internal  coat  does  not 
inflame  when  irritated ;  and  that  the  lymph,  when  present,  finds  its  way 
into  the  vein  from  without,  and  is  not  exuded  from  or  through  the  lining 
membrane. 

"From  these  considerations,"  he  says,  in  conclusion,  "it  is  manifest  that 
adhesive  phlebitis  has  been  very  variously  described  and  accounted  for,  and  that 
its  occurrence  has  been  denied  by  some  pathologists.  There  can  be  no  doubt 
but  that  veins  are  repaired  without  its  aid ;  and  experiments  upon  animals, 
taken  for  what  they  are  worth,  show  that  these  vessels  do  not  inflame  when 
irritated.  Absence  of  vessels  from  their  lining  membrane  points,  one  would 
think,  a  reason  for  this  immunity.  A  tissue  thus  circumstanced  may  eventually 
be  involved  when  adjacent  parts  are  affected,  but  it  does  not  originate  disease. 
As  the  barrier  between  tissues,  often  inflamed  on  the  one  hand,  and  the  blood- 
stream on  the  other,  it  would  obviously  discharge  an  important  function  did  it 
prevent  lymph  from  being  effused  on  the  internal  surface  of  the  vein.  For, 
although  "this  lymph  might  be  swept  away  without  producing  any  local  effect, 
it  could  not  be  mingled  with  the  blood  without  risk  of  spoiling  that  fluid,  or  of 
causing  secondary  mischief  by  becoming  entangled  in  and  so  obstructing  the 
capillary  vessels."  (p.  291.) 

Before  going  on  to  the  description  of  suppurative  phlebitis  or  diffuse 
inflammation  of  the  veins,  a  very  interesting  account  is  given  of  a  condition 
which  until  recently  has  been  too  often  confounded  with  inflammatory 
action — coagulation  of  blood  within  the  veins,  embolism,  or  thromballosis, 
as  Mr.  Callender  prefers  to  name  it.  The  nature,  causes,  and  consequences, 
as  well  as  the  diagnosis  and  treatment,  of  this  peculiar  disorder  of  the  cir- 
culation, are  very  carefully  explained  and  illustrated  in  the  course  of  about 
ten  pages,  which  are  well  worthy  of  the  reader's  attention. 

Suppurative  phlebitis  is  regarded  by  Mr.  Callender  as  "in  fact  nothing 
more  than  a  diffused  phlegmonous  inflammation,"  which  "follows  the 
course  of  veins  which,  acting  as  conductors,  favour  its  rapid  extension  in 
the  direction  of  least  resistance ;  and  hence,  as  a  rule,  the  disease  passes 
from  the  small  to  the  larger  vessels,  since  the  cellular  surroundings  of  the 
latter  offer  the  easier  route  for  its  advance."  We  cannot  follow  him  in  sup- 
port of  this  position,  which  we  believe  to  be  the  true  one,  and  well  sus- 
tained, or  in  the  excellent  account  of  the  disease  and  its  treatment,  and  the 
distinction  to  be  made  between  it  and  clot-obstruction,  or  thromballosis. 

The  next  most  important  topic  of  the  paper  is  phlebectasis  or  varicose 
veins.  He  calls  attention  to  the  fact,  known  to  hospital  surgeons  and 
especially  noted  by  recent  continental  writers  but  overlooked  by  Boyer  and 
others,  that  the  seat  of  varicose  disease  is  as  often  in  the  deep  veins  of  the 
lower  extremities  as  in  the  trunk  of  the  saphena,  or  in  that  of  any  of  the 
superficial  veins,  and  that  it  is  just  as  likely  to  commence  in  the  one  set  as 
in  the  other. 

The  management  of  varices  in  the  early  stage,  either  slightly  involving 
the  surface  vessels,  or  being  limited  to  the  deep  ones,  is  not  difficult,  and 
admits  of  permanent  benefit,  but  the  disorder  is  incurable  if  of  long  standing, 
although  capable  of  material  palliation.  From  all  the  measures  resorted 
to  for  the  purpose  of  obliteration,  we  are  justly  told — 


416 


Reviews. 


[April 


"It  is  quite  certain  that  only  a  temporary  benefit  is  obtained;  for  after  one 
mass  of  varices  has  been  removed,  the  anastomosing  veins  around  soon  acquire 
a  varicose  condition,  and  the  disease  is  perpetuated.  In  deciding  upon  perform- 
ing any  one  of  the  many  operations  open  to  choose  from,  it  must  be  the  relief, 
not  the  cure  of  the  varix  which  is  anticipated ;  and  no  doubt  there  are  cases, 
yet  not  so  many  as  some  would  have  us  to  believe,  in  which  the  pain  of  the 
varix,  the  impossibility  of  healing  a  large  ulcer,  the  unfitting  of  a  patient  for  his 
every  day  work,  justify  the  operation  for  the  temporary  benefit."  (p.  318.) 

We  have  long  since  given  up  the  hope  of  securing  more  than  a  temporary 
relief,  of  varying  amount  and  duration,  by  these  operations,  and  hence  accord 
entirely  with  this  rather  discouraging  view  of  an  expedient  which  is  too 
recklessly  resorted  to  by  young  operators.  We  agree  also  with  Mr.  Callen- 
der  in  the  opinion  that  the  danger  of  these  operations  on  varicose  veins, 
especially  with  the  caustic,  the  pin,  or  the  metallic  suture,  is  exaggerated, 
at  least  in  regard  to  properly  selected  cases.  The  liability  is  not  so  much 
in  the  veins  as  in  the  tissues  directly  around  them,  and  depends  not  on  the 
local  but  the  general  condition  of  the  patient.  This  general  condition, 
however,  from  the  very  nature  of  the  disease,  is  more  or  less  likely  to  be 
sufficiently  bad  to  render  the  radical  operations  dangerous,  even  when  the 
dyscrasy  may  be  very  slightly  manifested.  This  kind  of  interference,  therefore, 
can  only  be  justified  in  any  case  by  the  urgent  necessity  which  serious 
inconvenience,  suffering  or  positive  disability  may  create ;  and,  as  a  mat- 
ter of  course,  it  should  be  resorted  to  only  under  the  best  available  sanitary 
influences  and  precautions. 

The  first  of  the  essays  on  Diseases  of  the  Arteries,  gives  us  an  excellent 
account  of  atheroma,  and  obstruction,  including  embolism,  of  the  arteries, 
by  Mr.  C.  H.  Moore,  Surgeon  to  the  Middlesex  Hospital,  which  is  so  full  of 
interest  and  practical  instruction,  that  we  regret  our  inability  to  dwell  upon 
it  as  a  most  complete  expose  of  its  subjects.  This  is  followed  -by  an  ad- 
mirable clinical  monograph  on  aneurism,  by  Mr.  Holmes,  the  editor,  assisted 
in  certain  parts  by  Mr.  E.  A.  Hart,  Surgeon  to  the  West  London  Hospital. 

Mr.  Hart  contributes  the  sections  on  the  treatment  of  aneurism  by  digi- 
tal pressure,  by  flexion,  by  manipulation,  by  galvano-puncture,  by  coagu- 
lating injections  ;  also  those  on  arterio-venous  aneurism,  cirsoid  aneurism, 
and  aneurism  by  anastomosis.  Mr.  Holmes  gives  us  a  very  complete  and 
well  digested  view  of  all  the  other  branches  of  the  subject,  including  the 
regional  surgery  and  the  operations  on  the  various  arteries.  An  unusually 
clear  and  practical  exhibition  of  the  pathology  of  aneurism  is  given  in  the 
introductory  description  of  the  various  kinds  of  aneurism,  and  of  their 
causes  and  progress.  This  is  followed  by  a  comprehensive  and  equally  prac- 
tical inquiry  into  the  spontaneous  cure,  including  the  medical  treatment ; 
the  symptoms  and  the  diagnosis  ;  and,  lastly,  the  mechanical  treatment  of 
aneurism  by  the  various  methods. 

A  convenient  feature  of  the  introductory  portion  is  a  nomenclature  table, 
which  exhibits  the  terras  adopted  by  Mr.  Holmes,  in  parallel  columns  with 
those  used  by  the  French  and  English,  as  exemplified  in  Broca's  Treatise 
and  Erichsen's  Science  and  Art  of  Surgery.  This  table  is  useful  in  pre- 
senting the  author's  concise  and  accurate  anatomical  definitions,  while,  by 
comparing  his  nomenclature  with  that  in  common  use,  it  avoids  the  con- 
fusion and  ambiguity  which  even  the  practical  superiority  of  his  specific 
terms  would  not  justify  in  a  clinical  essay  on  a  class  of  anatomical  lesions 
which  are  intricate  enough  to  puzzle  the  student  under  any  circumstances. 

The  different  topics,  as  treated  by  Messrs.  Holmes  and  Hart,  are  full  of 


1863  ] 


Holmes,  A  System  of  Surgery. 


41t 


interest,  historically  as  well  as  practically,  and  are  abundantly  illustrated 
with  cases  and  statistics  drawn  from  all  sources,  among  which  those  of 
our  countrymen,  Gr.  W.  Norris  and  Stephen  Smith,  are  most  conspicuous. 
As  we  are  obliged  to  pass  on  to  other  portions  of  the  volume,  we  cannot 
give  a  better  idea  at  once  of  the  author's  mode  of  applying  practice  to 
theory,  and  of  his  views  in  regard  to  the  different  methods  of  treatment, 
than  by  quoting  from  his  general  remarks  in  relation  to  the  spontaneous 
cure  of  aneurism.  After  describing  the  different  processes  by  which  aneur- 
isms have  been  known  to  become  cured,  he  says  : — 

"  The  surgical  treatment  of  aneurism,  as  far  as  it  is  successful  and  rational,  is 
merely  an  artificial  imitation  of  these  processes.  The  treatment  most  in  use  in 
the  present  day,  that  by  compression  of  the  artery  above  the  tumour,  has  no  other 
aim  than  to  imitate  nature  in  the  first  of  the  processes  described  above,  so  as  to 
slacken  the  circulation  through  the  aneurism,  and  allow  the  blood  in  it  an  op- 
portunity of  coagulation.  ThVHunterian  operation  has  essentially  the  same 
object,  and,  although  it  accomplishes  it  in  a  somewhat  different  way,  and  by 
obliterating  a  portion  of  the  artery  above  the  tumour,  puts  a  more  decided,  but 
at  the  same  time  more  temporary  check  on  the  current  of  blood.  The  cure  by 
flexion  (Mr.  Hart's  method),  aims  at  combining  the  first  process  with  the 
second,  in  which  the  aneurism  is  compressed  by  the  parts  around  it,  and  itself 
(perhaps)  compresses  the  vessel.  Mr.  Fergusson's  plan  of  manipulation,  or 
crushing,  is  derived  from  observation  of  cases  in  which  the  natural  cure  was 
effected,  or  attempted,  by  the  impaction  of  a  clot  in  the  artery  leaving  the  sac. 
Brasdor's  method,  so  far  as  it  is  justifiable  at  all  in  practice,  i.  e.,  with  the  modi- 
fications hereafter  to  be  described,  is  identical  with  this  in  its  object,  and  rests 
upon  the  same  pathological  basis.  Direct  pressure  appears  to  cure  aneurism 
usually  by  displacing  portions  of  the  clot,  and  may,  perhaps,  sometimes  act  by 
setting  up  inflammation  in  the  sack  or  parts  around  it,  which  leads  to  coagula- 
tion. Finally,  the  old  method,  by  opening  the  sac  and  tying  both  ends  of  the 
artery,  bears  the  strongest  analogy  to  the  cure  by  suppuration,  and  is,  in  fact, 
a  kind  of  excision  of  the  tumour." 

"  The  methods  of  spontaneous  cure  have  been  dwelt  upon  at  this  length  with 
the  view  of  impressing  upon  the  mind  of  the  reader  that  all  successful  plans  of 
treatment  are  successful  from  being  imitations  (whether  designed  or  fortuitous) 
of  these  natural  processes,  in  the  hope  that  this  fact  may  lead  practitioners  to 
a  more  careful  study  of  the  workings  of  nature  in  this  particular,  and  the  con- 
ditions under  which  she  works.  Such  a  study  carried  on  by  various  observers, 
could  hardly  fail  to  be  fruitful  in  results  which  would  lead  to  the  preservation 
of  numerous  lives  that  would  be  sacrificed  to  the  idea  that  internal  aneurism  is 
a  disease  almost  necessarily  fatal.  What  else  is  it  than  the  careful  study  of  the 
natural  process  of  cure  that  led  Hunter  to  his  brilliant  and  daring  proposal  of 
tying  the  artery  away  from  the  seat  of  the  disease  ?  What  else  led  the  Irish 
surgeons  to  see  that  compression,  in  order  to  imitate  nature,  need  not  suspend 
the  circulation  entirely,  need  not  even  act  continuously ;  and  thus  to  substitute 
for  the  intolerable  torture  inflicted  by  the  old  plan  of  compression,  a  treatment 
which,  in  ordinary  cases,  is  harmless,  and,  in  a  few,  absolutely  painless  ?  Let 
us  remember  how  comparatively  short  a  time  it  is  since  one  of  the  most  cele- 
brated surgeons  of  his  time  (Pott,  Chir.  Works,  vol.  iii.  p.  220),  announced  his 
preference  for  amputation  over  all  other  methods  of  treating  popliteal  aneurism. 
Let  us  not  forget  that  one  of  our  most  justly  valued  living  authors  on  this  sub- 
ject (Hodgson,  Dis.  of  Arteries,  p.  190),  was  so  satisfied  with  the  advance  which 
had  been  made  at  the  time  he  was  then  writing,  as  to  express  his  opinion  that 
'the  improvements  that  have  been  effected  in  the  mode  of  applying  the  ligature 
to  arteries,  have  brought  the  surgical  treatment  of  aneurism  to  a  degree  of  per- 
fection which  leaves  but  little  room  for  advancement.'  Nor  was  such  an  appre- 
ciation of  modern  surgery  at  all  exaggerated  or  unreasonable  to  those  who 
looked  at  it  as  Mr.  Hodgson  did,  by  comparison  with  the  mortality  after  the  old 
operation.  In  our  times  surgery  has  made  such  rapid  advances,  that  the  mor- 
No.  XC— April  1863.  27 


418 


Reviews. 


[April 


tality,  which  under  the  system  praised  by  Mr.  Hodgson,  must  have  amounted  to 
a  large  percentage  of  those  operated  on,  is  now  very  much  reduced  by  the 
invention  of  instrumental  compression,  and  even  this  will,  no  doubt,  soon  be 
further  reduced  by  the  more  frequent  use  of  flexion  and  digital  pressure.  So 
may  it  be  in  medical  practice.  At  the  present  day,  it  is  hardly  too  much  to  say 
that  a  patient  with  internal  aneurism  is  condemned  to  death  as  certainly  as  one 
with  external  aneurism  used  to  be  to  amputation.  A  century  hence  we  may 
hope  our  descendants  will  have  as  solid  reason  to  boast  of  their  improvement 
upon  the  science  of  Watson  and  Latham,  as  we  have  to  congratulate  ourselves 
on  our  advance  upon  the  doctrines  of  Pott."  (pp.  371 — 373.) 

Under  the  head  of  organs  of  locomotion  and  innervation  we  have  a  short 
but  sufficiently  full  article  on  affections  of  the  muscular  system,  prepared 
by  Mr.  George  Tatum,  Surgeon  to  St.  George's  Hospital ;  a  concise  and 
comprehensive  practical  chapter  on  orthopedic  surgery,  illustrated  with 
woodcuts  and  very  useful,  by  Dr.  Little ;  another,  excellent  as  usual,  and 
equally  valuable,  on  diseases  of  the  bones,  by  the  editor,  Mr.  Holmes ;  a 
short  but  clear  and  comparatively  full  one  on  diseases  of  the  joints,  by  Mr. 
A.  A.  Johnson,  late  Surgeon  to  the  Hospital  for  Sick  Children  ;  a  careful 
summary  on  excision  of  bones  and  joints,  by  Mr.  Holmes ;  an  interesting 
paper  on  diseases  of  the  spine,  including  the  various  attendant  and  conse- 
cutive abscesses,  by  Mr.  A.  Shaw,  Surgeon  to  Middlesex  Hospital ;  and  a 
brief  but  characteristic  and  able  review  of  diseases  arising  from  injury  or 
other  lesion  of  the  nerves,  by  Dr.  Brown-Sequard.  The  volume  terminates 
with  an  interesting  essay  on  diseases  of  the  tongue,  by  Mr.  Holmes  Coote. 

Each  of  these  papers  presents  more  or  less  evidence  of  careful  study  as 
well  as  practical  familiarity  with  its  subject;  all  are  well  brought  up  in  the 
observations  of  the  day,  and  are  enriched  throughout  with  illustrative  cases. 
The  article  on  orthopaedic  surgery  is  particularly  interesting  in  its  patho- 
logy and  in  the  simplicity  and  practical  good  sense  of  its  various  directions, 
which  are,  by  the  by,  especially  authoritative  as  coming  from  one  of  the  first 
of  British  orthopaedists.  In  the  essay  on  diseases  of  the  bones,  Mr.  Holmes 
treats  at  length  of  simple  inflammation  and  its  consequences;  ostitis,  diffuse 
periostitis,  osteomyelitis,  chronic  abscess,  caries  and  necrosis  ;  constitutional 
disorders,  such  as  scrofula,  syphilis,  rheumatic  and  gouty  affections,  molli- 
ties  ossium,  cancer,  pulsatile  tumours,  and  cancerous  ulceration ;  non-ma- 
lignant tumours,  enchondroma,  exostosis,  diffused  bony  or  innocent  ostoid 
tumours,  serous  and  sanguinous  cystic  tumours,  fibrous  and  fibro-cystic  tu- 
mours and  entozoa  ;  hypertrophy  and  atrophy  ;  and  spontaneous  fracture. 

Among  these  topics  diffuse  periostitis,  osteomyelitis,  chronic  abscess, 
and  scrofula  in  bone,  appear  to  be  most  thoroughly  considered  by  Mr. 
Holmes.  The  first  two  are  well  known  to  have  attracted  increasing  atten- 
tion for  some  time  past ;  and  the  notices  of  them  in  this  volume,  as  very 
painful  and  often  dangerous  disorders,  will  reward  a  careful  study. 

In  his  paper  on  the  affections  of  the  joints,  Mr.  Johnson  treats  first  of 
diseases  common  to  all  the  joints,  and  secondly  of  diseases  of  individual 
joints.  In  the  first  part  the  diseases  of  the  synovial  membranes  are  first 
considered,  next  those  of  the  articular  extremities  of  the  bones,  of  the 
articular  cartilages,  and  of  other  tissues  in  and  around  the  joints ;  anchy- 
losis ;  articular  neuralgia ;  articular  hysteria ;  wounds  of  joints.  Part 
Second  includes  strumous  disease  of  the  hip ;  morbus  coxae  senilis ;  neu- 
ralgia of  the  hip;  diseases  of  the  pubic  and  sacro-iliac  joints;  of  the  knee; 
of  the  bursae  of  all  the  different  articulations. 

These  various  morbid  conditions  are  particularly  well  described  and  ex- 
plained, under  the  light  of  personal  experience  and  of  the  most  recent  views 


1863.] 


Holmes,  A  System  of  Surgery. 


419 


and  observations ;  but  the  details  of  treatment,  especially  the  mechanical 
portion  of  the  treatment,  are  scarcely  as  full  and  precise  as  they  might 
have  been  with  advantage,  and  as  they  are  generally  found  to  be  in  the 
different  papers  of  the  series. 

We  have  in  the  paper  on  excision  of  the  joints  a  cautious  but  intelligent 
and  liberal  summary  of  the  most  important  points  connected  with  the 
question  and  mode  of  performing  these  formidable  operations.  For  the 
history  of  excisions,  Mr.  Holmes  refers  in  a  very  complimentary  manner, 
to  the  excellent  and  elaborate  monograph  of  our  countryman,  Dr.  R.  M. 
Hodges,  of  Boston,  Mass.,  and  quotes  from  its  pages  repeatedly  in  the 
course  of  his  paper. 

Starting  with  the  admission  that  a  large  amount  of  success  has  attended 
the  attempt  to  preserve  limbs  by  the  removal  only  of  the  diseased  portions 
of  the  bone,  and  stating  his  acceptance  of  the  general  rule  that  a  large  or 
important  joint  ought  not  to  be  excised  while  any  reasonable  prospect 
exists  of  a  cure  without  operation,  he  thinks  that  a  surgeon  may  very 
reasonably  propose  to  cut  short  the  disease  by  removing  smaller  bones, 
externally  diseased,  and  easily  removable,  "  while  yet  he  may  allow  that 
cure  is  not  hopeless,"  under  favourable  circumstances.  He  has  often 
noted  excellent  results  from  the  excision  of  bones  of  the  tarsus  and 
metatarsus,  which  proved  the  superiority  of  such  treatment  to  that  of 
waiting  for  a  cure,  especially  in  children,  whose  restlessness  renders  con- 
finement less  likely  to  be  borne.  He  does  not  advocate  such  operations  in 
the  hand  and  wrist,  on  account  of  the  danger  to  the  tendons  in  operations, 
and  consequent  loss  of  motion,  which  would  not  be  likely  to  occur  from  the 
ordinary  inflammation.  The  question  between  excision  and  amputation  is 
far  more  frequently  perplexing  to  the  surgeon,  in  Mr.  Holmes'  opinion,  than 
that  between  excision  and  the  expectant  treatment,  except,  perhaps,  in 
cases  of  disease  of  the  hip-joint.  On  this  latter  question  he  presents  a 
careful  summary  of  the  general  indications  for  one  operation  or  the  other, 
under  four  heads,  as  follows  :  1,  the  situation  and  function  of  the  bone  or 
joint  to  be  excised;  2,  the  state  of  the  patient  as  to  general  health,  con- 
stitutional affection,  and  age ;  3,  the  nature  and  extent  of  the  disease ;  4, 
various  extraneous  circumstances.  These  general  indications  for  a  choice 
of  operation  are  followed  by  some  general  observations  on  the  operations 
themselves,  and  then  by  the  account  of  excisions  in  particular. 

The  paper  of  Dr.  Brown-Sequard  will  attract  attention  as  a  condensed 
and  lucid  exposition  of  a  very  important  series  of  morbid  phenomena,  by 
one  who  is  probably  more  competent  to  discuss  them  than  any  other  living 
writer — the  11  remote,  indirect,  or  reflex"  effects  of  irritation  of  nerves. 
It  is  particularly  interesting  to  us  at  the  present  time,  when  illustrative 
cases  are  accumulating  in  our  military  hospitals,  and  present  the  largest 
field  of  observation.    He  reminds  us  that — 

"Hardly  is  there  any  affection  that  cannot  be  considered  as  having  sometimes 
been  produced  by  a  reflex  action,  the  cause  of  which  is  an  injury,  a  disease,  or 
at  least  an  irritation  of  a  nerve.  If.  instead  of  confining  myself  to  the  lesions 
of  trunks  and  branches  of  nerves,  I  intended  to  describe  the  effects  of  irritation 
of  the  ramifications  of  nerves  in  the  skin  or  in  the  mucous  membranes,  I  could 
easily  prove  that  most  of  the  inflammations  of  the  various  thoracic  or  abdominal 
viscera  take  place  through  a  reflex  action,  the  starting  point  of  which  is  some 
irritation,  by  cold,  of  peripheric,  sensitive,  or  centripetal  nerve-fibres.  I  will  not 
say  more  here  about  this  influence  of  cold,  as  my  purpose,  as  already  stated,  is 
to  give  an  outline  of  the  reflex  effects  of  injuries  or  diseases  of  other  parts  of 
nerves  than  the  network  of  their  terminal  ramifications. 


420 


Reviews. 


[April 


"Of  the  various  reflex  effects  of  irritation  of  centripetal  nerves,  the  following 
are  the  principal,  of  which  I  propose  to  speak  successively :  epilepsy,  tetanus, 
hysteria,  chorea,  and  other  convulsive  affections,  paralysis  agitans,  -paralysis 
of  various  kinds  [hemiplegia,  local  paralysis,  &c),  amaurosis,  anaesthesia, 
insanity,  delirium,  coma,  neuralgia,  and  other  painful  affections,  inflamma- 
tion, atrophy,  and  other  morbid  alterations  of  nutrition  and  secretion.  After 
having  mentioned  clear  and  positive  facts,  showing  that  all  these  affections  may 
be  caused  by  an  injury  to,  or  a  disease  of,  a  nerve,  I  will  briefly  give  the  rules 
concerning  the  diagnosis  and  treatment  of  injuries  and  diseases  of  nerves.  This 
essay  will,  therefore,  consist  of  two  parts ;  the  first,  relating  to  facts  showing 
the  reflex  effects  of  irritation  of  centripetal  nerves ;  the  second,  the  principal 
features  and  rules  of  diagnosis,  and  treatment  of  diseases  and  injuries  of  branches 
and  trunks  of  nerves."  (p.  877.) 

A  very  large  number  of  curious  facts  are  cited  from  various  authorities 
in  illustration  and  support  of  the  views  of  reflex  action  described  in  the  first 
part.  In  the  second  part,  an  outline  of  the  means  of  diagnosis  and  the 
rules  of  treatment  is  given  in  a  very  few  words,  but  quite  sufficiently  for 
practical  purposes. 

The  cases  occurring  among  our  wounded  soldiers  of  lesion  of  the  nerves, 
especially  from  gunshot  wounds,  are  already  so  numerous  that  we  hope  to 
see  these  postulates  of  Brown-Sequard  thoroughly  tested,  if  not  confirmed, 
by  the  experience  of  the  war,  and  should  therefore  be  glad  to  see  his  import- 
ant chapter  separately  and  widely  circulated  in  the  United  States. 

We  are  unable  to  accompany  our  authors  any  further  in  their  interesting 
essays,  and  are  obliged  to  leave  them  and  the  remainder  of  their  volume  with- 
out further  discussion  of  its  very  useful  matter.  We  cannot  pretend  to  pre- 
sent more  than  a  very  superficial  glimpse  of  its  character  and  actual  contents. 
There  is  so  much  that  will  attract  the  surgical  student  and  practitioner, 
and  especially  the  hospital  surgeon,  that  there  can  be  no  fear  of  the  entire 
success  of  the  "system'7  in  the  hands  of  every  practical  reader;  and  we 
sincerely  trust  that  a  sufficient  number  of  copies  may  be  brought  into  this 
country  to  reach  some  portion  of  the  crowds  of  really  able  men,  whom  our 
military  service  is  rapidly  developing  into  veterans,  expert  in  the  manage- 
ment of  the  most  important  forms  of  surgical  disease  and  injury.  With 
such  opportunities  and  such  an  example  and  monitor  before  them,  in  the 
work  of  men  not  older  and  perhaps  less  experienced  than  themselves,  we 
may  hope  for  a  material  advance  in  the  surgical  teaching  of  this  country. 
We  shall  certainly  look  for  still  greater  strides  than  have  yet  been  taken 
in  the  actual  practice  of  surgery,  notwithstanding  all  that  has  been  done 
for  the  progress  of  the  art  and  science  within  the  last  half  century  on  both 
sides  of  the  Atlantic. 

E.  H. 


1863.] 


421 


BIBLIOGRAPHICAL  NOTICES. 

Art.  XVIIL—  Obstetrics:  The  Science  and  the  Art.  By  Charles  D.  Meigs, 
M.  D.,  etc.  etc.  Fourth  Edition,  revised.  With  one  hundred  and  twenty- 
nine  illustrations.    8vo.  pp.  730.    Philadelphia,  1863.    Blanchard  &  Lea. 

The  present  edition  of  Dr.  Meigs'  well-known  treatise  on  obstetrics  exhibits, 
throughout  every  chapter  and  section,  the  marks  of  the  careful  revision  to  which 
the  work  has  been  subjected  by  the  author,  and  the  very  decided  improvement 
it  has  undergone  by  reason,  as  well  of  omissions  from  the  text  as  of  additions  to 
it.  The  work,  notwithstanding  its  blemishes,  which,  though  prominent,  are  but 
few  in  number,  and  far  outnumbered  by  its  unquestioned  excellencies,  forms,  be- 
yond doubt,  one  of  our  very  best  treatises  on  the  science  and  the  art  of  midwifery, 
whether  regarded  in  the  character  of  a  guide  for  the  student,  or  as  a  counsellor 
in  the  hour  of  need  to  the  actively  engaged  practitioner.  In  respect  to  everything 
embraced  within  the  scope  of  obstetrical  practice,  in  the  strict  sense  of  the 
term,  we  know  of  no  work  from  which  more  sound,  clear  and  fuller  instruction 
is  to  be  derived  than  from  the  one  before  us. 

We  have  no  intention  to  enter  into  a  formal  criticism  of  the  treatise.  Its 
general  scope  and  peculiar  characteristics  have,  by  this  time,  become  pretty 
well  known  to  the  medical  profession,  in  this  country  at  least,  of  whom  the  almost 
unanimous  approval  has  been  conceded  to  the  work  as  an  exponent  of  the 
science  and  the  art  of  obstetrics.  All,  therefore,  that  would  seem  to  be  called 
for,  is  a  brief  notice  of  the  additions  and  improvements  by  which  this  fourth 
edition  is  distinguished  from  those  which  preceded.  We  shall  merely  refer  to 
one  or  two  points  in  the  teachings  of  the  author  to  which  our  attention  has 
been  attracted,  as  well  from  their  actual  importance  and  the  weight  which  must 
necessarily  be  attached  by  the  junior  members  of  the  profession  to  the  views 
held  in  respect  to  them  by  one  having  the  authority  of  Dr.  Meigs  as  an  ex- 
pounder and  practitioner  of  obstetrics. 

In  respect  to  the  use  of  anaesthetics  in  midwifery,  Dr.  Meigs  expresses  his 
opposition  as  strongly  in  the  present  as  he  had  in  the  former  editions  of  his 
treatise.  Notwithstanding  he  is  willing  to  admit  that  there  may  occur  some 
instances  in  which  the  parturient  woman  will  be  benefited  by  the  use  of  ether 
employed  as  an  anaesthetic,  he  contends  that  such  instances  must  be  extremely 
rare ;  while,  on  the  other  hand,  the  mischiefs,  he  contends,  arising  from  the 
lavish  and  indiscriminate  employment  of  anaesthetic  agents,  so  strongly  tempt- 
ing as  it  is,  are  many  and  of  a  very  serious  character. 

In  the  general  run  of  cases  of  natural  and  ordinary  labour  we  feel  well  per- 
suaded that  the  resort  to  any  anaesthetic  merely  to  get  rid  of  pain  is  entirely 
unjustifiable.  In  many  cases,  however,  of  labour  where  manual  or  instrumental 
interference  is  demanded,  or  in  cases  in  which  there  is  an  abnormal  amount  of 
pain  present,  or  when  the  labour  is  rendered  protracted  from  a  rigid  condition 
of  the  os  uteri,  vagina,  or  perineum;  as  well,  also,  in  cases  of  puerperal  eclamp- 
sia unattended  with  cerebral  congestion,  and  in  other  contingencies  occurring 
during  labour,  which  it  is  not  necessary  to  here  enumerate,  we  have  the  con- 
current testimony  of  the  most  distinguished  and  authoritative  obstetricians, 
that  the  employment  of  anaesthetics,  especially  pure  sulphuric  ether,  will  be 
productive  of  highly  beneficial  effects,  and  when  conducted  with  a  due  amount 
of  caution  is  attended  with  but  slight  danger. 

The  section  devoted  to  the  consideration  of  placenta  praevia  has  been  entirely 
recast  in  the  present  edition.  The  one  leading  indication  laid  down  by  Dr. 
Meigs  in  all  cases  of  placental  presentation  is,  as  soon  as  the  os  uteri  has  be- 


422 


Bibliographical  Notices. 


[April 


come  sufficiently  dilatable,  to  turn  the  child  and  deliver  by  the  feet.  The  views 
of  Drs.  Radford  and  Simpson  in  respect  to  the  treatment  of  placenta  prsevia, 
the  arguments  advanced  by  them  in  its  support,  and  their  experience  in  proof  of 
its  superior  efficacy,  receive  not  the  slightest  favour  at  the  hands  of  Dr.  Meigs. 

"  Let  no  man,"  the  latter  remarks,  "  suppose  me  to  be  so  bold,  not  to  say  so 
impudent,  as  to  call  in  question  the  perfect  good  faith  with  which  Messrs.  Rad- 
ford, Simpson,  and  others,  have  stated  their  experience ;  it  will  ever  be  far 
from  me  to  do  so,  though  I  can  find  in  the  mystery  of  their  success  no  other 
solution  than  the  errors  of  their  observations,  since  I  know — not  believe — that  a 
child  deprived  for  many  consecutive  hours  of  all  its  sources  of  aeration  must,  of 
necessity  die,  and  since  I  know  equally  well  that  when  the  os  is  not  very 
greatly  dilated  and  practicable  for  speedy  delivery  no  man  can,  or  will  ever  be 
able  to  detach  an  unassailable  implanted  placenta — unassailable,  I  say,  because 
it  lies  far  beyond  his  finger  points.  There  ought  to  be  a  public  recantation 
made  of  so  considerable  and  so  mischievous  an  error — an  error  that  assuredly 
will  not  long  withstand  the  light  of  the  nineteenth  century." 

We  would  recommend  to  the  young  practitioner  a  careful  study  of  the  entire 
section  devoted  to  the  consideration  of  placenta  praevia  and  its  treatment.  It 
will  be  found  particularly  instructive.  The  views  of  Dr.  Meigs  will,  we  believe, 
be  endorsed  by  the  great  majority  of  well-instructed  and  experienced  ob- 
stetricians. 

Whilst  pointing  out  the  very  serious  consequences  which  usually  result  from 
the  occurrence  of  smallpox  during  pregnancy,  especially  towards  its  latter 
period,  Dr.  Meigs  urges  upon  his  readers  not  only  the  immense  importance  of 
sedulously  guarding  the  pregnant  female  from  exposure  to  the  contagion  of 
variola,  but  of  abstaining  under  every  and  all  circumstances  from  subjecting 
her  to  vaccination. 

"  The  shocking  spectacles  of  distress  that  I  have  witnessed  from  the  vaccina- 
tion of  pregnant  females  have  so  impressed  my  mind,"  says  Dr.  Meigs,  "with 
the  enormity  of  the  imprudence,  that  nothing,  I  think,  could  tempt  me  to  com- 
mit it  myself.  The  most  furious  phlebitis,  which  is  endangitis,  and  which  be- 
comes pyaemic  fever,  is  one  of  the  consequences  likely  to  result  from  every  true 
or  spurious  vaccination  of  a  pregnant  female.  I  am  firmly  convinced  that  it  is 
far  better  for  the  physician,  during  an  epidemic  of  smallpox,  to  leave  his  preg- 
nant patient  to  the  chance  of  a  natural  infection,  than  to  certainly  bring  her 
within  the  range  of  its  virulent  power  by  a  vaccine  inoculation,  which  is  but  a 
variolous  inoculation  modified  by  the  generical  force  of  an  inferior  zoological 
genus.  If  I  venture  to  put  forth  such  opinions  as  the  above,  it  is  hardly  incum- 
bent upon  me  further  to  protest  against  the  temerity  of  those  who,  during  the 
existence  of  a  smallpox  epidemic,  recommend,  and  even  proffer,  what  is  called 
revaccination  to  those  who,  having  been  already  vaccinated,  might  be  held  to 
be  protected  ;  I  mean  to  pregnant  women.  I  have  seen  pregnant  women  very 
nigh  to  term,  unnecessarily  revaccinated,  with  consequences  so  terrific  that  I 
think  I  would  not,  for  a  thousand  golden  crowns,  either  vaccinate  or  revacci- 
nate  any  woman  knowing  her  to  be  pregnant." 

We  candidly  confess  that  the  foregoing  extract  embraces  statements  which 
to  us  are  as  novel  as  they  are  adverse  to  all  our  experience.  We  have  had  fre- 
quent occasion  to  vaccinate  females  during  pregnancy,  and  still  more  frequent 
occasion  to  revaccinate  such  individuals,  but  in  no  instance  have  we  known  any 
bad  symptom  or  the  slightest  evil  consequence  follow  the  operation.  We 
should  not,  certainly,  make  choice  of  the  period  of  pregnancy  to  either  vacci- 
nate or  revaccinate  our  female  patients ;  but  in  any  instance  where  there  was 
imminent  danger  of  a  pregnant  woman  being  attacked  by  smallpox,  in  conse- 
quence especially  of  its  prevalence  as  an  epidemic  in  her  immediate  neighbour- 
hood, we  should  consider  ourselves  warranted  in  securing  to  her  without  delay 
the  protection  afforded  by  the  lesser  evil,  vaccination — if  it  can,  indeed,  be  con- 
sidered in  any  sense  an  evil — against  the  much  to  be  dreaded  because  often 
deadly  effects  of  the  variolous  poison.  Nay,  we  should  consider  ourselves  dere- 
lict in  the  duty  we  owed  to  our  pregnant  patient  if  we  did  not,  under  the  cir- 
cumstances referred  to.  urge  her  to  submit  to  vaccination,  even  though  in  early 
life  it  had  been  already  performed  in  her  case. 


1863.] 


Bulletin  of  the  New  York  Academy  of  Medicine. 


423 


The  curious  argument  by  which  Dr.  Meigs  attempts  to  sustain  his  opposition 
to  vaccination  during  pregnancy,  will  hold  equally  good  against  the  safety  of 
vaccination  under  many  other  conditions.  Thus,  if  the  argument  be  at  all  valid, 
it  should  deter  us  from  resorting  to  vaccination  in  the  early  stages  of  life,  and 
in  the  midst  of  those  severe  epidemics  it  has  been  our  ill  fortune  more  than  once 
to  witness,  when  even  those  are  no  longer  safe  who,  at  other  times,  were  found 
proof  against  infection,  though  they  had  been  exposed  fully  to  the  action  of  the 
variolous  poison. 

The  peculiar  views  advanced  many  years  ago  by  Dr.  Meigs  in  respect  to  the 
pathology  and  treatment  of  what  he  denominates  "  child-bed  fever,"  are  re- 
iterated in  the  volume  before  us,  unmodified  in  the  slightest  degree  in  any  of 
their  features  by  the  vast  body  of  facts  in  elucidation  of  the  subject  that  has  of 
late  years  been  accumulated  by  medical  observers  everywhere.  These  facts  are 
as  completely  ignored  by  our  author  as  though  they  had  no  existence. 

A  correct  scientific  account  of  the  so-called  puerperal,  or  child-bed  fever,  is 
still  to  be  written.  Whether  we  have  as  yet  in  our  possession  all  the  materials 
requisite  for  the  preparation  of  such  an  account  may,  with  good  reason,  be 
doubted.  But  upon  a  careful  collation  and  analysis  of  all  the  recently  recorded 
facts,  observations  and  researches  directly  bearing  upon  the  subject,  every  un- 
prejudiced inquirer  will  be  obliged,  we  think,  to  admit  that,  under  the  term  "  puer- 
peral fever,"  meaning  thereby  to  indicate  a  single  special  fever  incident  to  the 
puerperal  state,  simply  varying  in  intensity  in  different  cases  and  in  its  different 
visitations,  there  has  been  in  fact  embraced  various  morbid  conditions  resulting 
from  very  different  causes,  attended  by  very  different  phenomena,  pursuing  a  very 
different  march,  presenting  very  distinct  pathological  lesions,  and  requiring  very 
dissimilar  courses  of  treatment.  And  while  it  is  found  that  the  so-called  puer- 
peral or  child-bed  fever  is  neither  a  single  nor  specific  disease,  it  will  as  clearly 
appear  that  the  several  morbid  conditions  which  have  thus  been  named  and 
classed,  are  not  confined  to  the  puerperal  period,  but  may  occur  to  woman  at 
any  period  of  her  life,  and  in  the  male  equally  as  the  female. 

Dr.  Meigs  will  find  few  among  his  contemporaries  in  the  profession,  either  at 
home  or  abroad,  willing  to  endorse  his  one-sided  and  exclusive  teachings  on  the 
subject  of  puerperal  fever,  or  the  treatment  to  which  he  believes  his  convictions 
as  to  the  true  pathology  of  the  disease  necessarily  lead.  They  will  soon  become 
— they  are  even  so  now — to  a  great  extent  exclusively  his  own. 

D.  F.  C. 


Art.  XIX.— Bulletin  of  the  New  York  Academy  of  Medicine,  from  January, 
1860,  to  October,  1862.  Instituted  1847.  Yol.  I.,  8vo.  pp.  588,  exclusive  of 
an  Appendix  of  6  pages.    Printed  for  the  Academy,  New  York,  1862. 

The  official  report,  presented  in  the  volume  before  us,  of  the  proceedings  of 
the  New  York  Academy  of  Medicine  for  the  last  three  years,  proves  very  clearly 
the  active  working  character  of  that  institution.  Besides  this  Bulletin,  the 
Academy  publish  also  from  time  to  time  a  volume  of  Transactions,  the  contents 
of  which  are  distinct  from  those  contained  in  the  Bulletin. 

The  many  valuable  communications  on  medical  subjects,  most  generally  of 
the  deepest  interest,  read  before  the  Academy  by  its  members,  and  the  animated 
discussions  to  which  they  almost  invariably  give  rise,  cannot  fail  to  render  its 
sessions  always  in  an  eminent  degree  instructive. 

It  is  the  free  interchange  of  experience  among  physicians  daily  engaged  in  the 
study  of  disease,  in  all  its  varied  forms,  amid  fields  peculiarly  adapted  for  the 
acquisition  of  medical  knowledge  and  skill,  and  in  the  careful  comparison  of  the 
deductions  obtained  by  each  from  their  individual  observations,  that  correct 
views  are  to  be  acquired  in  respect  to  the  nature  of  the  several  morbid  conditions 
to  which  the  human  organism  is  liable — the  phenomena  by  which  the  presence 
of  these  conditions,  respectively,  is  indicated — the  circumstances  under  which 


424 


Bibliographical  Notices. 


[April 


they  are  most  liable  to  occur,  and  the  treatment  best  adapted  to  conduct  them 
to  a  favourable  termination. 

The  closest  attention  to  the  papers  and  discussions  elicited  at  the  meetings 
of  the  best  conducted  medical  association,  it  is  very  evident  cannot  supply  the 
place  of  the  knowledge  to  be  derived  from  the  study  of  approved  professional 
writings  ;  such  attention  is  to  be  ranked,  nevertheless,  among  the  best  exponents 
of  the  nature  and  bearing  of  the  truths  set  forth  by  the  master  minds  of  our 
profession,  whether  past  or  present,  and  of  imparting  these  to  the  busy  practi- 
tioners who,  unfortunately,  have  little  time,  and  some,  we  fear,  less  inclination 
for  the  study  of  medical  works,  whether  new  or  old. 

The  entire  contents  of  the  volume  before  us  are  both  interesting  and  instruc- 
tive. As  the  more  prominent  among  the  communications  and  discussions  set 
forth  in  it,  we  would  enumerate  those  on  diphtheria  and  croup,  comprising  an 
inquiry  into  the  value  of  tracheotomy  in  the  treatment  of  the  latter;  on  the  use 
of  mechanical  means  in  the  treatment  of  uterine  diseases ;  on  tetanus ;  on  the 
treatment  of  morbus  coxarius ;  and  of  fractures  of  the  femur;  on  morbid  in- 
sanity in  relation  to  criminal  acts ;  on  the  use  of  anaesthetics  in  midwifery ;  on 
cretinism  ;  on  pelvic  hsematocele ;  on  epilepsy ;  on  inversion  of  the  uterus ;  on 
vaginismus ;  on  amputation  of  the  cervix  uteri,  and  on  albuminuria. 

The  communications  made  to  the  Academy  in  reference  to  the  subjects  just 
enumerated  are,  in  general,  well  drawn  up,  and  in  more  than  one  of  them  hints 
are  presented  of  a  highly  original  and  suggestive  character.  Several  of  the 
communications  are,  perhaps,  too  elaborate,  if  we  view  them  as  merely  intended 
to  form  the  foundation  for  a  discussion,  by  drawing  out  the  views  and  experience 
of  the  members  of  the  Academy,  in  respect  to  the  subjects  set  forth  in  them, 
-  while  they  are  seldom  sufficiently  full  to  enable  them  to  lay  claim  to  the  character 
of  finished  monographs.  Nevertheless,  nearly  every  communication  made  to 
the  Academy  appears  to  have  excited  discussion,  more  or  less  animated  and 
prolonged.  This  is  to  be  ascribed,  in  great  measure,  to  the  very  sensible  ar- 
rangement of  the  Academy,  by  which  the  discussion  of  any  given  topic  is  not 
confined  to  a  single  session,  nor  prohibited  from  being  revived  at  any  subsequent 
period,  should  any  member  desire  to  express  his  views  in  relation  thereto. 

It  is  not  our  intention  to  present  an  analysis  of  the  several  papers  which 
make  up  the  contents  of  the  volume  before  us,  or  to  criticize  the  manner  in 
which  their  respective  subjects  are  treated,  or  the  nature  of  the  views  set  forth 
in  each.  All  of  these  papers  had  been  already  some  time  before  the  public  in 
another  form,  previously  to  their  being  gathered  together  in  a  volume ;  and, 
with  the  particular  questions  discussed  in  them,  and  with  the  nature  of  the  con- 
clusions arrived  at  by  their  authors,  the  medical  public  are  sufficiently  familiar. 
The  Bulletin  is  nevertheless  well  worthy  of  a  place  in  the  library  of  every  phy- 
sician, by  no  one  of  whom  can  its  pages  be  consulted  without  profit. 

'   '  D.F.C. 


Art.  XX. — Registration  Reports  to  the  Legislature  of  Vermont,  comprising 
the  Registry  and  Returns  of  Births,  Marriages,  and  Deaths,  in  the  State, 
for  the  Years  1857, 1858,  1859,  respectively.  Prepared  under  the  Direction  of 
Benjamin  W.  Dean,  Secretary  of  State.    8vo.  pp.  118,  116,  119. 

The  vital  statistics  of  a  people  have  far  higher  uses  than  simply  to  minister 
to  a  spirit  of  mere  curiosity,  however  laudable  such  curiosity  may  be ;  .they  are 
capable  of  being  directed  to  the  attainment  of  results,  by  which  may  be  im- 
proved alike  the  comfort,  the  happiness,  and  the  prosperity  of  every  indi- 
vidual, even  the  humblest,  in  the  community,  the  vital  movement  of  which 
they  present.  Towards  a  full  and  correct  appreciation  of  the  means  best 
adapted  to  secure  to  a  people  the  highest  amount  of  health,  vigour,  and  lon- 
gevity, and  to  insure  their  advancement  in  prosperity,  civilization,  and  happi- 
ness, it  is  generally  conceded,  that  a  knowledge  of  the  circumstances  connected 
with  the  three  important  eras  of  existence — birth,  marriage,  and  death — affords 


1863.] 


Dean,  Registration  Reports  of  Vermont. 


425 


a  necessary  basis,  inasmuch  as  with  these  eras  are  most  intimately  connected 
the  physical,  moral,  and  civil  condition  of  the  human  race.  Even  though  the  sta- 
tistics be  confined  to  a  mere  exposition  of  the  comparative  mortality  of  different 
communities,  and  of  the  different  classes  of  which  these  communities  are  com- 
posed— arising  from  difference  of  sex  or  age,  or  from  difference  of  occupation  or 
pecuniary  position — they  become  of  sufficient  importance  to  warrant  all  the 
labour  and  expense  incident  to  their  collection  and  registration.  By  the  lights 
furnished  by  them  *we  may  remark — following  the  train  of  thought,  if  not  the 
exact  phraseology  of  another — the  governing  powers  and  enlightened  statesmen 
become  better  prepared  to  discharge  their  high  and  responsible  duties  to  the 
public,  by  the  more  exact  knowledge  furnished  them,  of  the  physical  and  vital 
powers,  the  possessions,  and  the  resources  of  their  constituents.  The  judiciary 
are  enabled  to  dispense  more  equal  justice  in  the  settlement  of  life  annuities, 
reversions,  entailments,  dower,  pensions,  and  similar  questions,  by  being  ren- 
dered more  intimately  acquainted  with  the  laws  which  govern  the  probabilities 
of  living — the  probable  duration  of  life — within  a  given  jurisdiction.  Those 
interested  in  life  insurance,  either  as  members  of  legalized  organizations,  or  as 
policy  holders — in  which  so  large  an  amount  of  capital  is  now  invested  by  our 
citizens  of  nearly  every  class — are  benefited,  by  being  furnished  with  a  correct 
exhibit  of  the  relation  which  the  laws  of  mortality,  in  respect  to  any  given  place 
or  community,  create  between  the  insurer  and  insured,  and  the  relative  interests 
of  the  two  parties  thence  resulting.  While  the  philanthropist  and  the  sanitarian 
will  be  enabled  to  give  more  defmitiveness  and  more  efficiency  to  their  labours, 
by  knowing  where,  in  what  manner,  and  in  which  direction,  they  must  direct 
their  efforts,  to  obtain  from  them  the  good  designed ;  a  knowledge  they  can 
acquire  only  by  an  acquaintance  with  the  laws  which  govern  the  issues  of  life 
and  death,  as  developed  by  a  sufficiently  extended  series  of  vital  statistics. 

In  this  country,  the  subject  of  vital  statistics  has  only  of  late  years  attracted 
the  attention  of  the  State  and  municipal  authorities  ;  and  only  in  a  few  of  the 
States  have  any  measures  been  taken  to  secure  a  full  and  accurate  registration 
of  the  births,  marriages,  and  deaths,  which  annually  take  place.  Even  the  medi- 
cal profession  have  not  been  as  active  in  forwarding,  by  their  aid  and  influence, 
this  important  movement,  as  would  reasonably  have  been  expected  of  them,  from 
their  presumed  acquaintance  with  the  benefits  to  result  from  it  to  the  commu- 
nity at  large,  and  the  valuable  materials  it  is  calculated  to  furnish  to  every  medi- 
cal practitioner,  in  his  study  of  the  etiology  and  prophylaxis  of  disease. 

Every  year,  however,  the  value  of  registration  is  becoming  more  evident,  and 
the  impediments  which  have  heretofore  stood  in  the  way  of  the  inauguration  of 
a  correct  and  efficient  system  of  registration  in  most,  at  least,  of  our  larger  cities 
and  towns,  are  rapidly  disappearing. 

The  first  object  to  be  obtained  by  a  system  of  registration,  is  to  amass 
authentic  facts  ;  the  legitimate  deductions  from  these  will  follow  afterwards. 
The  greater  the  number  of  facts  accumulated,  and  the  more  in  detail  they  are 
given,  the  safer,  more  comprehensive,  and  conclusive,  and,  consequently,  the 
more  satisfactory  and  useful,  it  must  be  evident,  will  be  the  deductions  to  which 
they  lead. 

To  take  the  most  striking  and  familiar  example  of  the  beneficial  working  of  a 
carefully  collected  and  properly  arranged  series  of  vital  statistics  of  any  given 
community.  When,  by  such  a  series,  it  shall  be  shown,  that  the  common  mor- 
tality, or  that  from  any  particular  malady,  exceeds  in  some  one  locality  or 
neighbourhood,  or  some  one  class  of  citizens,  whose  pursuits  and  general  habits 
of  life  are  similar,  that  in  other  localities  or  classes  of  the  community  ;  a  careful 
investigation  of  all  the  circumstances  in  which  the  sickly  locality  or  neighbour- 
hood, or  class  of  citizens,  differs  from  those  in  the  enjoyment  of  superior  nealth, 
will  very  generally  furnish  a  clue  to  the  nature  of  the  causes  by  which  their 
unhealthy  condition  is  produced,  and  to  the  means  best  adapted  for  the  abate- 
ment or  entire  extinction  of  such  morbific  agencies.  This,  which  is  a  very 
important  and  comprehensible  example  of  the  good  resulting  from  registration, 
as  the  basis  of  a  system  of  vital  statistics,  is  by  no  means  the  only  one  that  could 
be  adduced.  It  is  adapted  to  work  out  other  results,  equally  important  and 
beneficial,  and  which  could  not  be  obtained  excepting  by  it. 


426 


Bibliographical  Notices. 


[April 


The  several  annual  reports  of  the  registration  of  births,  marriages,  and  deaths 
which  occurred  in  the  State  of  Vermont,  from  1857,  when  the  law  providing  for 
such  registration  went  first  into  operation,  to  1859,  inclusive,  present  a  very 
fair  exposition  of  the  vital  movement  of  the  different  portions  of  the  State.  The 
statistics  presented  in  the  three  reports  are  well  arranged,  and  although  still 
deficient  in  completeness  and  fulness  of  detail,  there  is  exhibited  by  each  suc- 
ceeding report  evidence  of  a  decided  improvement  in  both  respects. 

It  would  be  a  pleasing  and  instructive  task  to  examine  in*  detail  the  leading 
facts,  in  each  branch  of  statistics,  developed  by  the  reports  before  us,  and  com- 
pare them  with  those  developed  by  the  registration  reports  for  other  portions 
of  the  United  States.  To  do  this,  however,  in  a  satisfactory  manner,  would 
unreasonably  swell  the  present  notice;  while  with  the  isolated  and  .imperfect 
data  at  present  in  our  possession,  it  would  scarcely  warrant  the  amount  of 
labour  necessary  for  the  accomplishment  of  the  task.  We  can  afford  space 
sufficient  only  for  the  notice  of  a  few  leading  particulars. 

The  number  of  births  reported  for  the  year  1857  was  6412  ;  namely,  3283  males, 
3071  females ;  58  sex  not  stated.  Of  these  children,  4164  of  the  parents  were 
Americans,  1397  foreigners,  and  of  851,  the  parentage  was  unknown.  Excess 
of  births  over  deaths,  2900. 

In  1858,  6477  births  are  reported  :  males,  3294;  females,  3142.  In  41  cases 
the  sex  is  not  stated.  The  parentage  was  American  in  4359  cases  ;  foreign  in 
1583  ;  and  unknown  in  535.    Excess  of  births  over  deaths,  2749. 

In  1859,  6545  births  were  reported  :  males  3351 ;  females,  3155  ;  in  39  cases 
the  sex  is  not  given.  The  parentage  was  American  in  4523  cases  ;  foreign  in 
1599,  and  unknown  in  423.    Excess  of  births  over  deaths,  2689. 

The  number  of  plurality  births  which  occurred  throughout  the  State  of  Ver- 
mont, during  1857,  was  92  ;  52  males  and  40  females.  One  set  of  triplets  is  re- 
ported to  have  occurred  in  the  month  of  September.  The  three  children  were  all 
females.  Two  of  them  died,  one  on  the  seventh,  and  the  other  on  the  thirteenth 
day.  The  remaining  child  was  living  at  the  date  of  the  report.  In  1858,  148 
cases  of  couplets  are  reported,  and  three  sets  of  triplets.  The  children  in  the 
first  of  these  latter  were  females — all  still-born  ;  in  the  second,  there  were  one 
male  and  two  females,  all  of  which  were  living  at  the  date  of  the  report.  In  the 
third  case,  there  was  one  male  and  two  females  ;  the  male  survived  four  days, 
and  one  of  the  females  five  days ;  the  other  female  was  alive  at  the  time  of  the 
report.  One  case  of  triplets  occurred  this  year  among  2132  parturients.  In 
1859,  the  number  of  couplets  was  128 :  87  males,  41  females  ;  of  these,  78  males, 
37  females  were  born  alive.  The  twin  cases  were  as  one  among  every  100  par- 
turients. The  greater  number  of  the  plurality  births  occurred  this  year  in  the 
month  of  November. 

By  the  census  of  1857,  there  was  in  Vermont  1  birth  during  1857  to  every  48 
persons,  and  by  the  registration  report,  one  in  every  50.  Both  calculations  are 
evidently  inaccurate. 

October  was  the  most  fruitful  month,  and  January  the  least  so.  During  the 
winter  months,  there  were  1435  births;  during  the  spring,  1574;  during  the 
summer,  1686,  and  during  the  autumn  1717. 

In  1858,  December  was  the  most  fruitful,  October  the  next,  and  February  the 
least  so.  During  the  first  quarter  of  the  year  there  were  1421  births ;  during 
the  second,  1578 ;  during  the  third,  1691 ;  and  during  the  fourth,  1736. 

The  returns  of  this  year  show  one  birth  among  every  49  of  the  population. 

In  1859,  October  was  the  most  fruitful  month,  and  January  the  least  so. 

The  following  are  the  births  in  the  different  quarters  of  the  year,  and  the  differ- 
ent seasons  : — 


First  Quarter, 


1454 
1646 
1715 
1700 


Winter 
Spring 
Summer 
Autumn 


1441 
1653 
1685 
1736 


Second 
Third 
Fourth 


One  birth  appears,  from  the  returns  of  1859,  to  have  occurred  in  every  48  of 
the  population.    It  is  very  probable,  however,  that  only  three-fourths  of  the 


1863.]  Dean,  Registration  Reports  of  Vermont.  427 


births  are  registered  ;  in  that  case  there  would  be  one  birth  to  38  of  the  popu- 
lation. 

In  1857,  no  illegitimate  birth  is  reported.  In  1858,  there  was  one  illegitimate 
birth  among  every  108  births.  In  1859,  one  illegitimate  birth  is  reported  in 
every  121. 

In  1857,  54  cases  of  still-born  children  are  reported,  namely,  26  males,  22 
females,  and  6  sex  unknown.  In  1858,  147  cases  are  reported ;  71  males,  50 
females ;  the  sex  of  the  remaining  26  not  mentioned.  In  1859,  167  cases  are 
reported  ;  80  males,  64  females  ;  and  23  of  which  the  sex  is  not  given. 

In  examining  the  mortuary  tables  embraced  in  the  reports  under  consideration, 
we  are  struck  with  the  number  of  deaths  which  they  present  from  diseases  of  the 
brain  and  great  nervous  centres  generally.    Thus  the  deaths  from  apoplexy,  in 

1857,  were  71 ;  in  1858,  49 ;  in  1859,  47— total,  167.  From  paralysis,  the 
deaths  were  in  1857,  73  ;  in  1858,  89  ;  in  1859,  79— total,  241.  From  cephalitis, 
the  deaths  were  in  1857,  51  ;  in  1858,  62;  in  1859,  42— total,  155.  From  dis- 
eases of  the  brain,  in  1857,  61  deaths  are  reported ;  in  1858,  48 ;  in  1859,  40 — 
total,  149.  From  convulsions,  66  deaths  are  reported  in  1857  ;  in  1858,  56  ;  in 
1859,  49 — total,  171.    From  hydrocephalus,  the  deaths  were  in  1857,  46  ;  in 

1858,  32  ;  in  1859,  51— total,  129.  From  epilepsy,  the  deaths  were  in  1857,  8; 
in  1858,  26 ;  in  1859,  24 — total,  58.  From  chorea,  six  deaths  were  reported ; 
two  in  each  of  the  three  years  1857,  '58,  '59.  Thus  giving,  for  the  three  years, 
a  total  of  1076  deaths  from  diseases  of  the  nervous  centres,  in  a  population  of 
about  355,000.  Upon  a  more  close  analysis  of  the  reports  before  us,  there  is  no 
doubt  but  that  the  above  total  would  be  still  further  increased. 

The  diseases  of  the  respiratory  organs  give  for  the  three  years  a  total  of 
deaths,  amounting  to  3363  ;  namely — Pneumonia :  in  1857,  163  ;  in  1858,  169  ; 
in  1859,  161— total,  493.  Diseases  of  lungs  :  in  1857,  56  ;  in  1858,  53 ;  in  1859, 
67— total,  176.  Abscess  of  lung :  in  1857,  2  ;  in  1859,  1— total,  3.  Bronchitis  : 
in  1857,  4 ;  in  1858,  12  ;  in  1859,  6— total,  20.  Influenza :  in  1857,  25  ;  in  1858, 
3  ;  in  1859,  4— total,  32.  Asthma  :  in  1857,  5  ;  in  1858,  3 ;  in  1859,  1— total,  9. 
Haemoptysis:  in  1858,  2  ;  in  1859,  5— total,  7.  Croup:  in  1857,  73;  in  1858, 
54  ;  in  1852,  64— total,  191.  Hooping  cough  :  in  1857.  26  ;  in  1858,  34 ;  in  1859, 
57— total,  117.  Pleurisy:  in  1857,  10  ;  in  1858,  7  ;  in  1859,  9— total,  26.  Hy- 
drothorax :  in  1857,  9;  in  1858,  8;  in  1859,  15 — total,  32.  Consumption:  in 
1857,  785  ;  in  1858,  738 ;  in  1859,  734— total,  2257.  Giving,  as  above  stated, 
for  three  years,  a  total  mortality  from  diseases  of  the  respiratory  organs  of 
3363,  which  is  less,  however,  than  what  actually  occurred. 

The  entire  mortality  from  fevers  during  the  three  years  amounted  to  1244 ; 
namely— from  typhoid  fever:  in  1857,  88  ;  in  1858,  116  ;  in  1859,  214— total, 
418.  From  typhus :  in  1857,  21 ;  in  1858,  38  ;  in  1859,  23— total,  82.  Scarlet: 
in  1857,  123;  in  1858,  275;  in  1859,  263— total,  661.  From  all  other  fevers 
during  the  three  years,  83  deaths  are  reported. 

The  entire  number  of  deaths  from  cancer  during  the  three  years  was  214 : 
namely— in  1857,  73 ;  in  1858,  63  ;  in  1859,  78. 

The  deaths  from  Dropsy  amounted  to  293;  namely — in  1857,  109;  in  1858, 
93  ;  in  1859,  91. 

The  deaths  from  Dysentery  amounted  to  247  ;  namely — in  1857,  71 ;  in  1858, 
97  ;  in  1859,  79. 

The  deaths  from  Measles  amounted  to  59  ;  namely — in  1857,  1 3  ;  in  1858, 17  ; 
in  1859,  29. 

The  deaths  from  Rheumatism  amounted  to  40  ;  namely — in  1857, 13  ;  in  1858, 
15  ;  in  1859,  12. 

The  deaths  from  Diseases  of  the  heart  amounted  to  393  ;  namely — in  1857, 
120  ;  in  1858,  141 ;  in  1859,  132. 

The  deaths  reported  as  of  the  puerperal  state  amounted  to  99  ;  namely — in 
1857,  26  ;  in  1858,  39  ;  in  1859,  34. 

In  1858, 14  deaths  were  reported  from  diphtheria,  and  in  1859,  60 — total,  74. 

From  delirium  tremens  and  intemperance  21  deaths  are  reported  :  3  in  1857  ; 
3  in  1858  ;  15  in  1859. 

From  Erysipelas  106  deaths  are  reported :  26  in  1857 ;  40  in  1858 ;  40  in 
1859. 


428 


Bibliographical  Notices. 


[April 


Twenty-four  cases  of  Suicide  are  reported  :  in  1857,  9;  in  1858,  4;  in  1859, 11. 

To  old  age  756  cases  of  death  are  referred  :  309  in  1857  ;  232  in  1858  ;  215  in 
1859.  The  patients  were  in  the  greater  number  of  cases  over  eighty  years  of 
age. 

We  have  referred  to  the  foregoing  items  in  the  mortuary  registers  recorded 
in  the  reports  before  us  from  the  fact,  that  if  the  registration  has  been  accu- 
rately made,  the  amount  of  mortality  from  some,  at  least,  of  the  diseases  indi- 
cated, when  compared  with  the  population  of  Yermont,  will  be  found  unusually 
large. 

Taking  the  reports  for  the  three  years,  1857,  '58,  '59,  and  comparing  them 
with  each  other,  it  will  be  found  that  in  Yermont,  more  than  one-seventh  of  the 
deaths  of  which  the  ages  are  given,  were  of  infants  under  one  year  of  age ; 
nearly  one-fourth  were  of  those  under  three  years,  and  about  one-third  in  children 
under  fifteen  years  of  age. 

"It  will  be  recollected,"  we  quote  the  words  of  the  report  for  1857,  "that  the 
number  of  males  exceeded  the  number  of  females  born,  hence  an  excess  of  male 
mortality  in  infancy  might  be  expected ;  but  the  excess  of  male  births  was  less 
than  three  per  cent.,  while  the  excess  of  male  mortality  under  one  year  is  six 
per  cent.  Between  the  ages  of  one  and  ten,  also,  more  boys  than  girls  die.  In 
youth  and  adult  age  the  heaviest  mortality  falls  upon  the  weaker  sex ;  while  in 
old  age,  including  all  over  sixty,  the  scale  again  turns  against  the  males.  This 
agrees  with  the  facts  developed  by  registration  reports  in  other  parts  of  the 
world.  In,  however,  Massachusetts,  Kentucky,  South  Carolina ;  in  England, 
France,  Austria,  in  fact  in  every  State  and  Country,  whose  reports  have  been 
examined,  with  reference  to  this  point,  the  excess  of  male  mortality,  at  the  ex- 
tremes of  life,  more  than  counterbalances  the  excess  of  female  mortality  of 
middle  life,  giving  universally,  an  excess  of  male  mortality,  when  all  ages  are 
included.  In  Yermont,  on  the  contrary,  the  excess  of  female  mortality  between 
the  ages  of  ten  and  sixty,  very  much  overbalances  the  excess  of  male  mortality 
at  all  other  ages,  giving  an  absolute  excess  of  female  mortality  when  all  ages 
are  included.  If  this  has  been  so  for  years  past,  it  will  readily  account  for  the 
excess  of  male  population,  while  the  New  England  States  generally  possess  an 
excess  of  female  population.  Of  each  100  deaths,  of  those  between  the  ages 
of  ten  and  sixty,  38  were  males,  and  62  were  females,  making  a  difference  of  24 
per  cent,  against  the  females.  Of  each  100  deaths  at  all  other  ages,  52  were 
males,  and  48  females,  a  difference  of  only  4  per  cent,  against  the  males.  In 
this  the  difference  in  the  numbers  of  the  two  sexes  living  is  not  taken  into  the 
account.  When  it  is  considered  that  "the  male  population  preponderates,  the 
difference  is  found  to  be  still  greater  against  the  females.  While  it  is  usually 
the  fact  that,  during  the  term  of  active  life  the  weaker  sex  are  subject  to  a 
heavier  mortality,  yet  it  does  not  readily  appear  why  the  burden  should  be  so 
much  heavier  in  this  State  than  elsewhere.  During  the  development  of  woman- 
hood, and  through  the  procreative  and  climacteric  periods,  the  female  system  is 
everywhere  subject  to  increased  liability  to  disease  and  death.  In  this  State, 
this  liability  to  disease  and  death,  compared  with  that  of  males  at  the  same  age, 
is  very  wonderfully  increased,  particularly  during  the  first  period,  that  of  de- 
velopment of  womanhood.  Of  1000  deaths  of  persons  between  the  ages  of  15 
and  20  years,  654  were  females,  while  only  346  were  males,  being  a  difference  of 
nearly  31  per  cent,  against  the  females,  and  this  notwithstanding  there  were 
actually  more  males  than  females  living  between  those  ages.  Taking  the  living 
population  into  the  account,  it  appears  that  one  death  occurred  among  16i 
females,  between  15  and  20  years  of  age,  while  only  one  among  318  males  took 
place,  being  .6199  per  cent,  for  females,  and  .3146  per  cent,  for  males,  or  almost 
two  females,  exactly,  to  one  male." 

It  appears,  however,  that  this  excess  of  female  mortality  is  not  equally  dis- 
tributed through  the  State,  some  of  the  counties  showing  an  excess  of  male 
mortality. 

In  the  second  report  the  same  excess  in  the  mortality  among  females  is  no- 
ticed to  have  occurred.  The  deaths  among  the  males  were  only  one  in  96,  or 
1.04  per  cent.,  while  among  females  it  was  one  in  every  81,  or  1.23  per  cent. 


1863.] 


Dean,  Registration  Reports  of  Vermont. 


429 


"Among  children,"  it  is  remarked,  "boys  possess  the  least  amount  of  vital 
stamina,  and  this  is  the  more  shown  when  the  still-born  children  are  taken  into 
the  account.  There  were  1,117  deaths  of  boys  to  every  1000  of  girls.  But 
during  the  period  of  development  of  womanhood,  and  through  the  procreative 
and  climacteric  periods,  females  seem  to  be  by  far  the  weaker  sex.  In  old  age 
there  seems  to  be  but  little  difference  in  the  vital  powers  of  the  sexes,  since  this 
year,  1858,  the  balance  is  slightly  against  the  females,  while  last  year  it  was  very 
slightly  against  the  males.  As  remarked  in  the  first  report,  in  middle  life 
females  are  everywhere  subject  to  greater  liability  to  disease  and  death  . than 
males ;  while  in  this  State  this  liability  compared  with  that  of  the  males  at  the 
same  age,  is  wonderfully  increased,  particularly  during  the  period  of  development 
of  womanhood.  It  completely  overbalances  the  excess  of  male  mortality  at  the 
extremes  of  life,  producing  an  absolute  excess  of  female  mortality  in  this  State 
notwithstanding  the  excess  of  male  population.  There  is  scarcely  another 
State  or  Country  in  the  world  where  the  male  mortality  does  not  preponderate. 
What  causes  are  in  operation  in  Vermont  to  produce  this  comparatively  large 
female  mortality  ?" 

The  same  astonishing  fact  is  developed  by  the  report  for  1859.  The  deaths 
this  year  were  one  in  89  among  the  males,  and  one  in  80  among  females.  In 
England,  where  the  ages  of  the  population  are  so  nearly  like  our  own,  if  1 00 
females  die  out  of  a  given  number  of  females  in  a  given  time,  out  of  an  equal 
number  of  males,  107  males  die  in  the  same  time.  In  Vermont,  if  out  of  a  certain 
number  of  females,  100  die  in  a  given  time ;  out  of  the  same  number  of  males 
only  88  die  in  the  same  time,  taking  the  ratio  as  given  by  the  returns  for  1859. 
In  England  and  America,  we  may  remark,  the  ratio  of  the  sexes  at  birth  range 
from  104  to  109  boys  to  each  100  girls.  In  Vermont  nearly  the  same  ratio  ob- 
tains, it  being  106  boys  to  100  girls. 

In  two  of  the  counties,  Essex  and  Orleans,  the  percentage  of  deaths  is  greater 
for  males  than  for  females ;  while  in  Addison  county,  the  percentage  is  the 
same  for  both  sexes. 

In  1857  the  greatest  number  of  deaths  occurred  in  October,  the  least  in  Feb- 
ruary. The  number  of  deaths  were  great  in  March.  June  appears  to  be  a 
healthy  month,  giving  a  less  number  of  deaths  than  any  other,  excepting  Feb- 
ruary. 

Seven  persons  over  100  years  of  age  died  this  year. 

In  1858  the  greatest  number  of  deaths  occurred  within  the  first  quarter  of 
the  year,  whereas  in  1857  the  least  number  occurred  then,  and  the  greatest 
number  in  the  last  quarter.  Combining  the  two  years,  we  find  that  the  greatest 
mortality  took  place  during  the  middle  six  months,  including  the  winter  of  1857 
-8,  nearly  one-third  of  the  deaths  having  occurred  during  the  latter  season. 
The  winter,  it  is  remarked,  was  not,  perhaps,  particularly  unhealthy,  but  only 
more  so  than  the  other  portions  of  the  two  years. 

March  appears  to  have  been  the  most  fatal  month,  and  November  the  least  so. 

No  case  of  death  in  any  one  at  or  over  100  years  of  age  is  recorded. 
Twelve  deaths  were  returned  in  persons  over  95. 

September  was  the  most  destructive  to  life  during  1859.  January  was  the 
least  fatal.  In  Vermont,  March  and  November  are  equal  in  their  range  of  mor- 
tality, next  to  these  is  September;  August  ranks  the  fifth  among  the  months  in 
reference  to  extent  of  mortality. 

Twenty-one  deaths  are  registered  in  1859  as  having  occurred  in  persons  at 
and  over  95  years  of  age.  The  oldest  of  these  were,  one  over  99  years,  and  one 
at  100 ;  two  turned  of  100,  and  one  at  107.  D.  F.  C. 


430 


Bibliographical  Notices. 


[April 


Art.  XXI.: — The  Principles  and  Practice  of  Obstetrics.  By  Gunning  S.  Bed- 
ford, A.M.,  M.D.,  Professor  of  Obstetrics,  the  Diseases  of  Women  and 
Children,  and  Clinical  Obstetrics  in  the  University  of  New  York,  etc.  etc. 
Third  edition,  carefully  revised  and  enlarged.  New  York,  1863.  8vo.  pp. 
743.    William  Wood  &  Co. 

The  volume  before  us  claims  to  be  a  third  edition,  revised  and  enlarged,  of 
Dr.  Bedford's  lectures  on  the  principles  and  practice  of  obstetrics.  After  a 
very  careful  examination  of  it,  however,  we  have  not  been  able  to  detect  any 
material  difference  between  it  and  the  preceding  editions.  It  appears  to  us  to 
be  simply  a  reprint  of  those,  with  an  additional  chapter  (Lecture  xlvi.)  on  the 
pathology  and  treatment  of  phlegmasia  dolens,  of  which  disease  in  the  previous 
editions  no  account  had  been  given. 

There  seems  to  us  to  be,  in  this  practice  of  announcing  as  a  new  edition  each 
successive  impression  of  a  work,  however  small  in  number,  taken  from  the  same 
stereotype  plates,  an  appearance  of  deception  which  is  to  be  deprecated.  Such 
a  course  may  be  required  to  bolster  up  the  character  of  some  work  of  doubtful 
value,  by  leading  the  public  to  believe  that  the  demand  for  it  has  been  greater 
than  it  actually  was.  No  such  deceit,  we  feel  assured,  is  called  for  in  the  case 
of  a  professional  treatise  of  the  high  character  of  the  one  before  us.  The 
success  of  such  a  work  as  that  of  Dr.  Bedford,  it  seems  to  us,  may  be  very 
confidently  trusted  to  its  own  merits. 

We  feel  no  way  inclined  to  modify  in  the  slightest  degree  the  verdict  we  gave 
in  favour  of  these  lectures  of  Dr.  Bedford  upon  their  first  appearance  in  print. 
A  more  intimate  acquaintance  with  them,  acquired  in  a  careful  re-examination 
of  the  manner  in  which  their  author  has  handled  the  several  questions  embraced 
in  his  subject,  has  convinced  us  of  their  reliability  as  a  guide  to  the  study  of 
midwifery  in  all  its  details,  as  well  from  the  general  accuracy  as  from  the  clear- 
ness and  precision  of  their  teachings. 

We  cannot,  it  is  true,  fully  coincide  with  the  lecturer  in  all  his  views,  theo- 
retical or  practical ;  but  the  points  upon  which  we  diner  from  him  are  in  the 
main  open  questions,  in  relation  to  which  individual  experience  and  convictions 
will  necessarily  lead  to  differences  of  opinion,  until  a  more  extended  and  decisive 
series  of  observations  shall  warrant  one  or  other  party  to  dogmatize  in  respect 
to  them.  D.  F.  C. 


Art.  XXII.  —  First  Outlines  of  a  Dictionary  of  the  Solubility  of  Chemical 
Substances.  By  Frank  H.  Storer.  Part  I.  Cambridge,  Mass.,  Sever  k 
Francis.    8vo.  pp.  232. 

Mr.  Storer  is  well  known  to  chemists  by  the  numerous  original  investigations 
which  he  has  made  and  published,  and  which  have  been  extensively  reprinted 
in  the  German,  English  and  French  chemical  journals.  In  the  present  work, 
he  has  undertaken  to  collect  and  classify  all  the  facts  scattered  through  the 
vast  domain  of  chemical  literature  which  bear  upon  the  relations  that  exist 
between  chemical  substances  and  their  solvents.  The  labour  requisite  for  the 
conscientious  performance  of  such  a  task  has  been  necessarily  immense,  and 
will  be  fully  appreciated  by  the  chemical  world. 

Mr.  Storer  takes  the  term  "solubility"  in  its  extended  sense,  including  the 
reactions  of  liquids  upon  solids,  gases,  and  upon  other  liquids.  He  also 
embraces,  as  far  as  determined  by  observers,  the  influence  which  one  substance 
in  a  state  of  solution  exerts  upon  the  subsequent  solution  of  other  substances 
in  the  same  medium.  The  extent  and  variety  of  the  information  which  he  has 
collected  on  these  points,  will  relieve  the  chemist  from  long  and  troublesome 


1863.]   Storer,  Dictionary  of  Solubility  of  Chemical  Substances.  431 


searches  through  successive  treatises.  Tt  will  have  another  still  more  useful 
effect.  Bringing  together  the  various  statements  which  have  been  made  by 
different  observers,  any  one  consulting  Mr.  Storer's  dictionary  is  enabled  to 
ascertain  whether  these  statements  are  concurrent,  and  therefore  probably 
exact,  or  discordant,  and  therefore  liable  to  doubt.  In  a  word,  the  inquirer  has 
placed  before  him  the  best  information  which  has  been  published  on  each  par- 
ticular point,  and  is  placed  in  a  position  either  to  conclude  that  the  statements 
are  reliable,  or  to  perceive  that  he  must  determine  for  himself  the  question 
which  occupies  him.  Another  advantage  of  this  dictionary  consists  in  its  bring- 
ing together  a  very  complete  synonymy,  and  in  glancing  over  it,  one  is  forcibly 
struck  by  the  carelessness  which  has  led  chemists  to  use  names  already  pre- 
occupied, often  to  a  most  perplexing  extent.  For  example ;  there  are  three 
different  substances  to  which  the  name  of  Camphene  has  been  affixed,  all  by 
French  chemists,  and  one  with  the  very  similar  name  of  Camphin.  The  word 
Benzoin  belongs  to  three  substances ;  and  other  instances  might  be  cited.  Mr. 
Storer's  work  might  be  advantageously  consulted  by  investigators  before  adopt- 
ing names  for  new  substances,  in  order  to  assure  themselves  that  the  proposed 
word  has  the  requisite  novelty. 

A  dictionary  of  this  sort  is  so  necessary,  that,  as  in  many  similar  cases,  when 
the  work  is  done,  we  are  surprised  that  the  need  was  not  perceived  and  supplied 
before.  It  has  been  a  great  mistake  in  chemical  works  that  too  much  has  been 
attempted,  too  wide  a  scope  chosen,  so  that  even  with  the  most  herculean  efforts, 
completeness  has  not  been  attained.  Books  have  been  written,  intended  to 
embrace  as  far  as  possible,  the  sum  of  chemical  knowledge,  and  the  result  has 
been,  that  the  first  portions  have  become  antiquated  before  the  work  was  com- 
pleted. Gmelin's  Chemistry,  especially  the  Cavendish  Edition,  is  a  truly 
wonderful  work,  but  it  is  still  unfinished,  while  the  first  volume  (Physical 
Chemistry) ,  which  appeared  in  1848,  is  quite  out  of  date.  Poggendorffs  Hand- 
worterbuch  has  now  reached  the  letter  S,  and  already  the  first  part  has  had  to 
be  completely  re-written,  to  the  extent  of  four  large  octavos,  as  a  second  edition 
of  the  first  portion  of  a  work  still  far  from  complete.  And  this,  although  the 
book  is  not  the  production  of  any  single  hand,  but  the  result  of  the  cooperation 
of  many  labourers  in  the  field.  It  seems,  therefore,  desirable  that  chemical 
science  should  be  subdivided  into  as  many  specialties  as  possible.  In  this 
direction  we  regard  Mr.  Storer's  publication  as  a  most  valuable  step.  In  the 
present  state  of  the  science  we  want  monographs.  Some  such  have  been  at- 
tempted. Rose's  works  on  Analysis  were  admirable  examples.  Hoffmann  pub- 
lished a  monograph  on  Compound  Ammonias,  now  unfortunately  wholly  out  of 
print.  Hartung-Schwartzkopf  has  given  us  a  monograph  on  the  organic 
alkaloids.    Others  might  be  cited,  and  we  hope  the  number  will  be  multiplied. 

One  pressing  need  at  the  present  time  is  a  really  complete  work  on  qualita- 
tive reactions.  Rose  has  done  much  in  this  direction,  but  his  book  is  now  far 
behind  the  needs  of  the  science  of  the  day,  and  can  only  be  considered  as 
elementary.  He  has  restricted  himself  to  a  limited  number  of  reactions  for  each 
substance,  selecting  of  course  the  most  important,  and  has  discussed  them  in 
712  pages  of  rather  large  print.  A  thorough  collection  of  all  the  known  facts 
would  fill  two  or  three  times  as  much  space,  and  be  of  immense  value.  It 
should  be  subdivided  into  an  organic  and  an  inorganic  portion,  which  might 
constitute  separate  works. 

The  first  part  of  Mr.  Storer's  work  before  us  contains  232  double  column 
pages  of  close  but  clear  type,  and  extends  to  the  word  "  convolvulinol."  We 
hope  the  rest  of  the  work  may  speedily  follow.  M.  C.  L. 


432 


Bibliographical  Notices. 


[April 


Art.  XXIII. — Reports  of  Institutions  for  the  Insane  in  the  British  American 
Provinces : — 

1.  Of  the  Provincial  Lunatic  Asylum  at  Toronto,  Canada  West,  for  the 

years  1853  to  1861,  inclusive. 

2.  Of  the  Provincial  Lunatic  Asylum  of  New  Brunswick,  at  St.  John,  f&r 

the  years  1858  to  1861,  inclusive. 

3.  Of  the  Provincial  H&pital  for  the  Insane,  near  Halifax,  Nova  Scotia,  for 

the  years  1858,  1860,  and  1861. 

Through  the  polite  attention  of  the  superintendents  of  the  public  hospitals 
for  the  insane  in  the  three  British  American  Provinces,  Canada,  New  Bruns- 
wick, and  Nova  Scotia,  we  are  in  possession  of  most  of  the  annual  reports  which 
have  issued  from  those  several  institutions.  As  our  interest  in  the  insane  is  not 
limited  by  national  boundaries,  as  the  superintendents  mentioned  are  members  of 
the  American  Association,  and  one  of  them  at  least,  has  contributed  liberally 
to  the  original  matter  published  in  the  American  Journal  of  Insanity,  as  we 
feel  bound  especially  to  chronicle  the  progress  of  psychological  science  upon 
this  continent,  and  as  some  of  these  reports  contain  matter  of  general  interest, 
we  proceed  to  pass  them  under  a  brief  review. 

On  the  21st  of  January,  1841,  the  old  gaol,  near  the  centre  of  the  city  of 
Toronto,  Canada  West,  was  opened  as  a  temporary  receptacle  for  the  insane, 
where  they  were  not  only  furnished  with  the  ordinary  necessities  of  an  "  asylum," 
but  were  placed  under  curative  treatment.  In  the  course  of  a  few  years,  two 
other  buildings  within  the  limits  of  the  city  were  occupied  for  the  same  purpose, 
and  the  three  were  continued  in  operation  until  the  establishment  now  known  as 
the  "  Provincial  Lunatic  Asylum"  was  ready  for  occupation.  This  was  on  the 
26th  of  January,  1850. 

Patients  admitted  into  the  temporary  hospitals  ....  889 


Transferred,  date  above-mentioned,  to  the  new  hospital     .       .  112 

It  has  been  a  principle  from  the  beginning,  at  Toronto,  to  discharge  no  patient 
uncured.  Hence,  in  the  reports,  "discharged"  implies  "cured."  According  to 
the  above  statistics,  then,  the  proportion  of  cures  at  these  temporary  recepta- 
cles, all  unsuited  to  their  purpose  as  were  the  buildings,  and  unsupplied  with 
the  many  resources  for  treatment  considered  necessary  at  the  present  day, 
was  but  a  fraction  less  than  sixty-three  per  cent. 

The  report  very  properly  pronounces  the  figures  unreliable,  and,  as  evidence 
of  their  character,  shows  that,  in  one  case,  the  patient  died  in  the  hospital, 
three  years  and  five  months  after  the  time  of  first  admission,  but,  in  the  course 
of  that  period,  had  been  "discharged"  (cured,  of  course)  five  times ;  and  in 
another,  the  patient,  in  the  course  of  a  few  days  more  than  five  and  a  half 
years,  was  "discharged"  (cured)  seven  times,  and  then,  after  an  absence  of  only 
twenty-three  days,  returned  and  remained,  incurable,  until  death.  "Figures 
may  be  used  to  prove  anything,"  justly  saith  Dr.  Workman,  in  one  of  the  re- 
ports before  us. 

The  Provincial  Lunatic  Asylum  is  in  the  western  suburbs  of  Toronto,  near 
the  shore  of  Lake  Ontario,  upon  which  it  fronts.  It  is  a  large,  rectilinear 
building,  six  hundred  feet  in  length,  and  consisting  of  a  central  edifice  and  two 
opposite  wings.  The  original  design  included  two  additional  wings,  which  have 
never  been  erected.  The  internal  arrangements,  made  in  conformity  with  that 
design,  are  such  that  the  patients  of  either  sex  can  be  separated  into  but  three 
classes — one  in  each  story  of  the  wing.  This  want  of  proper  classification  is, 
and  must  continue  to  be,  so  long  as  it  exists,  a  great  and  glaring  defect. 

During  the  first  year  of  the  operations  of  the  asylum,  it  was,  if  we  mistake 
not — there  being  no  statement  upon  the  point  in  the  reports — under  the  super- 
intendence of  Dr.  Teller.    For  one  and  a  half  years  afterwards  it  was  under 


Discharged 


554 
211 


Died 


1863.]  Institutions  for  Insane  in  the  British  American  Provinces,  433 


Dr.  Scott,  who,  upon  the  1st  of  July,  1853,  was  succeeded  by  Dr.  Joseph 
Workman,  the  present  incumbent,  and  the  author  of  all  the  reports  now  under 
review. 

We  visited  the  establishment  in  the  summer  of  1852,  and  returned  with  im- 
pressions of  cheerless  grounds,  large  original  expenditure  in  the  building, 
enormous  halls  and  corridors,  bare  walls,  scarcity  of  furniture,  incomplete 
classification,  great  defect  in  the  means  of  moral  treatment,  and  the  laxity  of 
an  undisciplined  asylum  where  we  should  have  seen  the  regularity  and  order  of 
a  well  appointed  and  vigorously  managed  hospital. 

Dr.  Workman,  having  more  time  than  was  at  our  command,  found  other  im- 
perfections, not  the  feast  of  which  was  in  the  sewerage.  Drains  had  been  made 
beneath  the  building  and  a  main  sewer  excavated,  twenty-two  feet  distant  from 
the  outer  walls ;  but,  by  a  singular  oversight,  the  two  had  never  been  connected. 
Hence,  all  the  drainage  of  the  building,  from  the  time  it  was  first  occupied, 
had  accumulated  beneath  the  basement  floor — a  mass  of  filth  reeking  with 
noxious  effluvia,  which  penetrated  every  apartment  and  seriously  affected  the 
health  of  the  inmates.    This  evil  was  soon  thoroughly  corrected. 

Evidently  bringing  to  his  task  a  natural  taste  for  the  specialty,  sound  common 
sense,  practical  ability,  industry,  energy  of  action,  the  spirit  of  improvement,  and 
a  disposition  to  make  his  labours  contribute  to  the  advancement  of  science,  the 
present  superintendent  has  not  only  become  a  well-known  author  upon  insanity, 
but  has  gradually  brought  the  institution  under  his  charge  into  a  condition  in 
which  it  may  fairly  claim  to  rank  among  the  best  upon  the  continent.  In  the 
report  for  1855-6,  he  says,  "In  point  of  architectural  device,  excellence  of  work- 
manship, and  the  general  suitableness  of  its  interior  arrangements,  the  Toronto 
Asylum  is  inferior  to  none  on  this  continent."  Again,  in  the  report  for  1856-7, 
"An  extended  and  minute  examination  of  nearly  all  the  best  asylums  in  the 
United  States,  enables  me  to  state  that  the  sanitary  condition  of  our  Provin- 
cial Institution  for  the  Insane  is  not  inferior  to  that  of  any  in  America,  and  is 
much  better  than  the  majority.  It  is  my  belief  that  the  chief  cause  of  the 
comparatively  vigorous  health  of  the  patients  of  our  asylum,  is  to  be  found  in 
the  simplicity,  and  the  superior  nutritive  properties  of  their  diet,  as  contrasted 
with  the  more  varied  and  less  digestible  fare  with  which  the  inmates  of  Ameri- 
can Asylums  are  indulged."  And  finally,  in  the  report  for  1861:  "The  institu- 
tion continues  to  receive  a  liberal  gratuitous  supply  of  the  respectable  news- 
papers of  the  Province.  *  *  *  Our  library  is  pretty  well  stocked  with  books 
suitable  to  our  people.  *  *  *  Our  corridors  and  sitting-rooms  present,  I 
think,  a  better  and  more  numerous  collection  of  pictures  than  any  other  asylum 
I  have  visited.  Our  shrubberies,  flower-beds,  and  fountains  have,  in  summer, 
invested  the  asylum  with  a  pleasing  aspect.  *  *  *  Musical  entertainments, 
picnics,  moderate  dancing  and  occasional  holiday  festivals  combine  to  enliven, 
invigorate,  or  soothe  the  enfeebled  sufferers  who  come  here  for  renewal  of  mental 
and  bodily  health.  It  is  now  understood  by  candidates  for  discharge,  that  they 
have  to  attain  a  certain  degree  of  fatness  before  they  can  be  set  at  liberty,  and 
that  those  who  are  bad  eaters  must  remain  long.  Our  annual  bill  for  drugs  is 
not  formidable." 

The  reviewer  thinks  that  the  metamorphosis,  in  the  latitude  and  longitude  of 
the  Toronto  Asylum,  must  have  been  somewhat  remarkable  since  the  year  1852. 

When  Dr.  Workman  took  charge  of  the  asylum,  there  were  345  patients,  of 
whom  187  were  males  and  158  females.  In  February,  1856,  the  number  was 
370,  of  whom  183  were  males  and  187  females,  and  in  the  report  for  that  year 
the  completion  of  the  building  is  strongly  urged.  "  The  asylum  is  full — over- 
crowded— and  cannot  offer  admittance  to  all  who  call  for  and  require  it ;  but  it 
is  a  question  of  money  against  humanity;  of  '  public  benevolence'  against  public 
apathy  ;  of  God's  charity  against  man's  avarice."  It  appears  that  this  home- 
thrust  produced  its  proper  effects.  There  were,  however,  objections,  in  the 
minds  of  some  persons,  to  the  enlargement  of  the  asylum,  and,  as  a  substitute 
for  such  enlargement,  the  University  building  in  Toronto  was  opened  ' as  an 
"Auxiliary  Female  Asylum,"  at  some  period  before  the  close  of  February, 
1857.    This  was  occupied  by  "quiet  and  harmless"  patients. 

In  the  summer  of  1859,  the  calls  for  still  further  accommodations  having 
No.  XC— April  1863.  28 


434 


Bibliographical  Notices. 


[April 


173 

175 

348 

7 

62 

69 

20 

24 

44 

200 

261 

461 

308 

352 

660 

become  imperative,  the  barracks  at  Fort  Maiden,  near  Amherstburg,  were  also 
converted  into  a  "  Branch  Asylum,"  under  the  care  of  Dr.  Fisher,  formerly 
assistant  physician  to  Dr.  Workman ;  and  in  July,  October,  and  December, 
three  detachments  of  quiet,  incurable  patients,  forming  a  total  of  146,  one-half 
of  either  sex,  were  transmitted  to  it  from  the  main  establishment. 

On  the  3d  of  August,  1861,  the  "Orillia  Branch"  was  opened,  and  received 
44  patients  from  the  Asylum  at  Toronto. 

The  Asylum  at  Fort  Maiden  was  made  independent  of  the  parent  institution 
on  the  24th  of  September,  1861,  and  seven  counties  were  assigned  ^o  it  as  the 
district  from  which  it  is  to  receive  its  patients.  The  number  of  patients,  at  the 
time  of  separation,  was,  males  108,  females  91,  total  199.  The  number  remain- 
ing at  the  other  three  establishments,  at  the  close  of  the  year  1861,  was — 

Men.   Women.  Total. 

In  the  Chief  Asylum,  Toronto  . 
In  the  University  Branch  . 
In  the  Orillia  Branch 
Total        .  . 

Whole  number,  including  Fort  Maiden 
Hence  the  number  of  patients  in  asylum  has  doubled  since  July,  1853. 

Men.  Women.  Total. 

Patients  admitted  from  1841  to  1861,  inclusive  .    1416     1217  2633 

Discharged   790       625  1415 

Died  701 

For  cause  already  mentioned,  the  number  discharged  cannot  be  relied  upon 
as  the  number  of  cures.  In  the  8£  years  of  Dr.  Workman's  .administration, 
the  admission  and  discharges  were  as  follows : — 

Men.  Women.  Total. 

Admitted   612       639  1251 

Discharged   322      303  625 

This  makes  the  cures  {discharges)  equal  to  50  per  cent. ;  but  Dr.  W.  acknow- 
ledges that  "  a  small  percentage  of  deduction  is  to  be  made  for  unrecovered 
patients  removed  by  their  friends."  What  is  a  "  small  percentage  ?"  Is  it  1, 
or  5,  or  10  per  cent.?  Why  doesn't  he  say,  directly,  in  his  reports,  "Cured 
 so  many?"  That  would  be  much  more  consistent  with  the  general  direct- 
ness and  plainness  of  speech  which  is  a  prominent  characteristic  of  his  writings. 
For  ourselves,  we  think  it  very  probable  that  his  50  per  cent,  is  at  least  8  per 
cent,  higher  than  truth  will  warrant.  If  an  institute  which  receives  all  classes  of 
patients,  without  discrimination,  can  report  even  40  per  cent,  of  actual  cures,  it 
"does  well,  acts  nobly." 

In  the  first  nine  years  of  the  existence  of  the  asylum,  the  number  of  male  pa- 
tients exceeded  that  of  females  by  more  than  50  per  cent. ;  but  in  the  last  8£ 
years,  the  number  of  females  admitted  was  greater  by  27  than  that  of  males. 

"  In  a  given  aggregate  of  male  and  female  patients,"  says  the  report  for  1861, 
"it  is  found,  here,  that  more  single  men  and  women  than  married  men  and 
women  recover ;  not,  however,  because  they  are  single,  but  because  they  are 
younger." 

It  appears  that  Dr.  Workman  has  as  little  confidence  as  some  others  in  many 
of  the  causes  of  insanity,  as  alleged  by  the  friends  or  physicians  of  the  patients ; 
and  thinks  also,  with  others,  that  not  unfrequently  that  which  is  considered  the 
cause  is  rather  the  effect  of  the  mental  disorder.  In  the  report  for  1858,  after 
quoting  from  his  register  a  number  of  the  influences  to  which  insanity  was 
attributed,  he  proceeds  to  make  the  following  commentary : — 

"  Now,  if  any  one  of  the  preceding  wide-spread  agencies  may  be  regarded  as 
adequate  to  the  overthrow  of  reason,  bow  many  lunatics  would  this  Province 
contain  ?  Intemperance  alone  would  people  fifty  asylums  as  large  as  our  pre- 
sent one.  Jealous  wives  and  husbands  would  probably  fill  thirty.  Bad  treat- 
ment of  (by?)  husbands  wou],d  equal  intemperance.  Political  excitement  would 
people  a  mad-house  in  every  county,  and  one  of  superior  class  and  size  in  the 


1863.]  Institutions  for  Insane  in  the  British  American  Provinces.  435 


metropolis.  Religious  controversy  would  send  in  half  the  clergy  of  this  Pro- 
vince, and  large  detachments  of  their  congregations.  Tobacco  and  slander 
would  leave  few  in  Canada  at  large.  Excessive  study,  solar  eclipses,  love, 
inhalation  of  the  laughing  gas,  and  remorse  of  conscience,  would  probably  make 
up  but  a  small  aggregate.  In  651  cases  of  lunacy  admitted  by  me  into  this 
Asylum,  I  have  met  with  only  one  instance  in  which  the  last-named  agency  was 
alleged  as  the  cause  of  the  insanity,  and  the  patient  had  not  been  very  wicked. 

■  ■  Religious  excitement  and  religious  despair  both  come  in  for  their  full  share 
of  censure,  and  yet  we  meet  with  few  cases  in  which  either  can  be  regarded  as 
purely  casual.  Those  who  are  already  half  insane,  or  strongly  predisposed  to 
flie  malady,  are  very  likely  to  rush  into  the  former  or  to  reason  themselves  into 
the  latter. 

"  On  the  other  hand,  we  cannot  question  the  efficiency  of  such  agencies  as  the 
following:  Gestation;  puerperal  disorder;  over  lactation;  fevers  resulting  in 
cerebral  lesion ;  sun-stroke ;  intense  cold  to  the  head ;  injuries  of  the  skull ; 
apoplexy;  epilepsy;  parental  intemperance  ;  masturbation ;  scrofulous  and  syphi- 
litic taint ;  defective  diet,  &c.  &c." 

The  following  remarks  are  taken  from  the  report  of  1860 : — 
"No  (other)  question  is  so  frequently  put  to  the  physician  of  a  lunatic  asylum 
as  that  which  calls  upon  him  to  state  the  most  productive  cause  of  insanity. 
Those  who  are  most  familiar  with  insanity  find  themselves  the  least  able  to 
reply  to  this  question.  The  reader  of  one  book,  or  the  doctor  of  one  patient, 
is  sure  to  understand  disease  and  its  cure  much  better  than  the  student  of  half 
a  century." 

The  opinions  expressed  in  the  two  extracts  given  below  do  not  accord  with 
those  generally  quoted  from  American  reports.  As  our  views  upon  the  subjects 
have  been  fully  exposed  in  former  "notices,"  we  shall  withhold  them  here. 

"  A  lunatic  asylum  is,  in  many  respects,  the  best  place  for  the  treatment  of 
the  insane  ;  but  the  transmission  of  every  case  of  the  malady  to  an  institution 
of  this  character  is  neither  necessary  nor  advisable.  Under  no  consideration 
other  than  that  of  unavoidable  necessity  should  any  fellow-being  be  cast  into  a 
mad-house."1  (Report  for  1857.) 

"  It  is  very  doubtful  if  the  efficiency  of  early  treatment  has  not,  by  many  of 
the  specialty,  been  much  overrated.  When,  for  example,  we  are  told  that  90 
out  of  every  100  would  recover  if  put  under  asylum  treatment  within  the  first 
month,  we  may  be  cautious  in  crediting  the  assertion.  There  are  cases  of  in- 
sanity, and  1  fear  the  proportion  is  formidable,  in  which  treatment  cannot  effect 
a  cure,  at  whatever  period  it  may  be  commenced.  This  is  a  fact  which  will 
readily  be  verified  by  many  a  disappointed  asylum  physician." — Report  for  1861. 

Lest,  however,  we  may  misrepresent  our  author,  it  may  be  stated  that  he 
acknowledges  the  importance  of  early  treatment,  and  even  says  :  "  It  is,  indeed, 
to  be  deplored  that  in  many  instances  insanity  is  allowed  to  root  itself  in  the 
system  before  the  friends  of  patients  can  resolve  to  place  them  in  an  asylum ; 
and  thus  incalculable  evil  is  done.  *  *  *  *  It  is  very  far  from  my  desire  to 
discourage  early  transmissions  to  the  asylum ;  but  it  is  my  duty  to  admonish 
against  the  entertainment  of  expectations  which  actual  facts  do  not  warrant." 

We  will  now  turn  our  attention  to  such  parts  of  the  reports  as  relate  to  some 
of  the  forms  of  insanity. 

"  Reasoning  mania,  in  many  of  its  varieties,  is  a  formidable  type  of  mental 
disease ;  and  under  the  august  sanction  of  religious  dogmatism  it  assumes,  per- 
haps, its  most  obstinate  and  alarming  form.  Suicidal  propensity  is  seldom 
absent  in  such  cases. 

"  Among  the  religious  (mania)  cases  admitted  in  the  past  year  (1859)  there 
have  been  found  a  number  who  accuse  themselves  of  having  committed  '  the 
unpardonable  sin,'  and  in  consequence  believe  themselves  doomed  to  inevitable 
perdition.    If  those  who  teach  doctrines  of  this  character  were,  by  law,  sen- 


1  Does  not  Dr.  Workman  perceive  that  the  continued  use  of  such  words  as 
" mad-house,"  "lunacy,"  "wards,"  &c,  tends  to  perpetuate  the  prejudices  and 
false  notions  which  have  hitherto  been  among  the  objections  to  the  commitment 
of  an  insane  person  to  a  hospital  ? 


436 


Bibliographical  Notices. 


[April 


tenced  to  serve  a  definite  period  in  the  Asylum,  nursing  the  victims  of  their 
dogmas,  and  guarding  them  from  self-destruction,  it  would,  perhaps,  tend  to  the 
removal  of  the  evil.  I  have  seen  one  patient  whose  case  might  well  have  taught 
discretion  to  a  thousand.  *  *  *  *  These  patients  require  for  their  benefit 
the  mental  vacuity  of  a  mad-house.  They  should  be  placed  among  those  who 
cannot  or  will  not  argue  with  them." 

The  subjoined  is  an  abridgment  from  the  report  for  1861 : — 

"  The  past  year  has  been  most  fearful  in  the  annals  of  this  Asylum  as  regards 
the  number  of  suicidal  patients  admitted.  No  less  than  53  of  the  204  have 
been  certified  to  be  suicidal.  *  *  *  *  I  think  I  am  warranted  in  regarding 
this  unwonted  manifestation  of  insane  propensity  as  an  epidemic.  *  *  *  * 
The  malady  has  presented  itself  under  strongly  marked  religious  complexion ; 
yet  it  has  differed  from  the  sporadic  suicidal  insanity  of  other  years,  in  the  fact 
that  it  has  shown  no  incidental  partiality.  It  has  neither  known  distinction  of 
creed  nor  of  nationality ;  and  although  the  religious  delirium  or  delusions  asso- 
ciated with  it  may  have  found  expression  in  diversified  phraseology,  yet  the 
generic,  underlying  mental  error  has  been  the  same  in  all.  They  all  believed 
they  had  committed  unpardonable  sin." 

Bat  one  death  from  suicide,  in  the  course  of  the  year,  is  reported. 

Our  readers  are  aware  of  the  general  belief  that  the  paralysis  peculiar  to  the 
insane  is  chiefly  produced  by  intemperance  and  venereal  excesses.  In  his  report 
for  1859.  Dr.  Workman  says  : — 

"  In  this  Asylum  12  cases  have  terminated  in  death  since  I  entered,  and  two 
were  taken  home  by  their  friends  shortly  before  death.  All  occurred  in  men, 
and  only  in  three  could  I  discover  proofs  of  intemperance.  Yet  in  these  three 
does  sound  philosophy  warrant  the  assertion  that  their  known  intemperance  was 
the  cause  of  the  disease  of  the  brain  of  which  they  died  ?  If  so,  what  produced 
the  disease  in  the  remaining  nine  ?" 

In  the  report  for  1860  he  says  :  "The  experience  of  another  year  has  tended 
to  confirm  my  belief  that,  in  this  country  at  least,  the  disease  presents  itself 
almost  exclusively  in  temperate  men." 

He  alludes,  in  the  report  for  1859,  to  the  opinion  that  ramollissement  of  the 
brain  always  accompanies  the  disease,  and  presents  the  following  summary  of 
the  results  of  his  own  observations : — 

"In  the  majority  of  subjects  I  have- found  softening,  but  greatly  diversified  as 
to  extent  and  locality.  In  a  few  instances,  instead  of  softening,  I  have  found 
unequivocal  hardening.  The  least  inconstant  fact  has  been  serous  effusion, 
within  the  ventricles  and  on  the  surface ;  and  in  two  or  three  cases  this  was  the 
only  morbid  result  observed.  Thickening  and  opacity  of  the  membranes  are 
generally  met  with,  and  lymphy  deposits,  of  varying  consistence,  over  the  sulci 
of  the  convolutions,  are  not  uncommon." 

Those  sections  of  the  reports  which  relate  to  the  care  and  the  treatment  of 
the  patients  demand  a  passing  notice. 

"  It  is  my  belief  that  insanity  is  never  associated  with  perfect  bodily  health  ; 
in  the  majority  of  cases  it  is  certainly  dependent  on  physical  debility.  *  *  * 
Many  patients  come  to  this  Asylum  in  a  very  reduced  state,  and  not  a  few  have 
been  placed  beyond  the  reach  of  curative  means  in  consequence  of  the  active 
and  depressing  therapeutic  measures  which  have  been  adopted  by  their  physi- 
cians. Blood-letting,  purging,  vomiting,  salivation,  blistering,  cupping,  setons, 
low  diet,  and  the  whole  battery  of  medical  destructives  have  been  exhausted  : 
and  it  is  fortunate  if  the  patient  has  fallen  into  the  hands  of  only  one  of  this 
class  of  psychologists.  The  most  promising  cases  are  generally  those  for  which 
least  has  been  done. 

"Were  generous  diet,  well-directed  kindness,  exemption  from  bodily  restraints, 
moderate  exercise,  and  in  many  cases  a  judicious  allowance  of  wine  or  alcoholic 
beverages  substituted  for  the  present  erroneous  medical  treatment,  a  very  large 
proportion  of  those  who  are  now  sent  to  this  Asylum  would  recover  at  home, 
and  many  who  are  rendered  incurable  for  life  might  be  saved  from  so  melancholy 
a  doom."  {Report for  1857.) 

"  To  live  among  the  insane  is  but  to  be  irresistibly  constrained  to  pity  and  to 
love  them ;  and  when  this  bond  is  once  established  between  the  physician  and 


1863.]  Institutions  for  Insane  in  the  British  American  Provinces.  437 


his  confiding  family,  the  task  of  governing  becomes,  so  far  as  they  are  concerned, 
a  labour  of  inconceivable  pleasure.  But  the  superintendent  of  an  insane  Asy- 
lum has  other  people  to  manage  and  govern  besides  his  patients.  *  *  *  So 
long  as  the  insane  were  regarded  as  malignant,  blood-thirsty,  treacherous,  vin- 
dictive, and  implacable,  and  their  malady  was  ascribed  to  demoniac  possession, 
they  were  indeed  treated  as  the  devil's  children  ought  to  be.  But  the  devil  has 
much  less  to  do  with  the  inmates  of  an  insane  hospital  than  with  those  outside 
who  are  called  sane.  I  believe  there  is  no  asylum  superintendent  who  would 
not  rather  undertake  the  government  of  five  hundred  lunatics  than  of  fifty  sane 
persons  taken  indiscriminately  from  society."  (Report for  1858.) 

"  Kindness  to  the  insane  inmates  of  an  asylum  sometimes  demands,  of  those 
in  command,  the  execution  of  much  that  is  considered  very  unkind  to  the  sane 
attendants.  Small  faults  must  be  promptly  dealt  with,  otherwise  great  ones  will 
spring  from  the  overlooking  of  them.  Even  an  ill-natured  attendant  may  be 
kind  to  a  good  and  obliging  patient;  it  requires  a  vigilant  oversight  to  secure, 
from  the  best  tempered  attendant,  the  like  treatment  of  the  malevolent  and 
perverse."  (Report  for  1860.) 

"  Nothing  (else)  contributes  so  much  to  the  improvement  and  cure  of  the 
male  patients  of  this  asylum,  as  the  employment  afforded  by  the  farm."  (Report 
for  1855.) 

The  pictures  in  the  building  have  already  been  mentioned.  "  It  is  a  gratify- 
ing fact,"  says  the  report  for  1858,  "that  in  the  course  of  three  years  but  two 
instances  have  occurred  of  wilful  injury  to  these  ornaments.  In  one  the  offence 
was  committed  by  a  male  patient,  in  a  fit  of  aberration ;  and  in  the  other  by  a 
female,  in  a  state  of  lucid  termagancy,  which  probably  had  been  her  normal 
condition  at  home." 

"  Curing  insanity  is  not  all  the  good  we  can  do  in  asylums  ;  might  I  not  say, 
it  is  a  small  part  of  the  good?  Fifty  years  ago  lunatics  recovered  in  asylums, 
notwithstanding  that  they  were  then  subjected  to  treatment  very  different  from 
that  of  the  present'  day.  It  must  not  be  to  statistics  that  we  shall  appeal  to 
prove  the  superiority  of  modern  asylums  and  modern  treatment.  Its  most 
worthy  proofs  must  be  sought  for,  I  apprehend,  rather  among  the  incurable, 
than  the  curable,  insane."  (Report  for  1861.) 

A  few  passages  connected  with  the  mortality  of  the  insane  are  worthy  of 
reproduction. 

"Chronic  insanity  terminates  frequently  in  complicated  or  obscure  forms  of 
disease,  to  which  it  is  very  difficult  to  assign  any  definite  nosological  designa- 
tion. The  ultimate  symptoms  of  the  case  may  appear,  to  ordinary  observers, 
clearly  enough  indicative  of  the  final  pathological  state  of  the  organs  then  most 
prominently  affected ;  but  to  the  physician  who  has  observed  the  long  series  of 
morbid  phenomena  which  have  preceded  and  determined  the  closing  scene,  they 
are  suggestive  of  associated  facts  imperfectly  appreciated  by  others. 

"Exhaustive  diarrhoea,  terminating,  as  it  does  so  often,  both  chronic  and 
acute  insanity,  may  appear,  in  itself,  a  sufficient  fatal  agency ;  yet  it  is  but  the 
last,  and  the  least  interesting,  of  a  long  succession  of  morbid  occurrences,  which 
have  passed  in  review  under  the  daily  observance  of  the  asylum  physician.  It 
has,  perhaps,  been  present  again  and  again,  during  the  progress  of  the  case,  as 
a  symptomatic  accompaniment  of  unyielding  disease  of  the  brain,  to  the  relief 
of  which  nature  probably  sent  it ;  and  having  accomplished  its  mission,  it  sub- 
sided, apparently  controlled  by  the  medical  remedies  employed  to  check  it.  It 
has  now  once  more  come  to  the  rescue ;  but  its  weapons,  like  those  of  other 
members  of  the  healing  art,  are  double-edged — striking  at  the  disease  it  kills 
the  organ."  (Report  for  1859.) 

"  Disparity  between  the  mortality  of  male  and  female  lunatics  is  a  well-known 
fact  in  asylum  statistics.  In  a  large  aggregate,  the  mortality  of  male  lunatics 
is  to  that  of  the  other  sex,  probably  as  4  to  3  *  *  *  *  Female  insanity 
is,  in  a  large  proportion  of  cases,  merely  a  reflex  disturbance  of  the  brain. 
Insanity  in  men  much  more  extensively  involves  cerebral  lesion ;  and  their 
mortality  is  proportionally  increased."  (Report  for  1860.) 

Of  the  42  deaths  in  1861,  no  less  than  21,  or  50  per  cent,  of  the  whole,  are 
attributed  to  pulmonary  consumption.  Dr.  Workman  shows  that,  in  several  of 


438 


Bibliographical  Notices. 


[April 


the  hospitals  of  the  United  States,  only  20  per  cent,  of  the  deaths  are  reported 
as  having  been  the  result  of  that  disease.  He  refuses  to  admit  that  phthisis  is 
more  prevalent  among  the  insane  of  Canada  than  among  the  insane  of  the 
United  States,  asks  whence  arises  the  apparent  difference?  and  says:  "The 
reply  is  simple  and  satisfactory.  Our  Canadian  diagnosis  is  based  on  post- 
mortem examination,  whilst  in  the  United  States  asylums,  post-mortem  exami- 
nations are  not  held,  unless  exceptionally. 

"  Had  not  examination  post-mortem  revealed  to  me  destructive  tuberculous 
disease,  in  numerous  instances  it  would  not  he  known  to  have  existed.  Of  the 
21  patients  whose  deaths  I  ascribe  to  this  disease,  only  three  had  both  cough 
and  expectoration,  and  only  three  or  four  others  had  any  expectoration.  All 
the  rest  died  without  these  symptoms." 

Several  of  the  reports  are  enriched  with  the  records  of  many  autopsies. 

In  July,  1857,  "  a  quantity  of  imported  potatoes  affected  with  the  European 
rot  were  purchased  for  the  use  of  the  patients,  and  shortly  afterwards  several 
cases  of  severe  dysentery  and  other  formidable  diseases  of  the  digestive  organs, 
evincing  a  marked  typhoid  type,  occurred."  The  remaining  potatoes  having 
been  buried,  "  the  health  of  the  patients  speedily  returned  to  its  wonted  state." 

With  two  or  three  miscellaneous  extracts  we  shall  close  this  notice,  already 
protracted  beyond  our  customary  limits.  The  first  one  is  as  applicable  in  some 
of  our  States  as  it  is  in  Canada.  It  refers  to  the  oath,  legally  required,  that  the 
insane  person  is  "  dangerous  to  be  at  large." 

"Among  the  'dangerous  to  be  at  large'  lunatics  sent  from  our  gaols  in  1860, 
was  one  paralytic  in  the  lower  extremities,  and  who,  in  the  asylum,  is  as  gentle 
as  a  child.  *  *  *  *  Along  with  the  above  patient  was  brought  another 
' dangerous  lunatic'  who  is  certainly  one  of  the  most  gentle  creatures  I  have 
ever  seen  in  this  house.  *,.*.:**  How  do  the  parties  swearing  manage 
the  task?  and  how  do  the  magistrates  permit  the  oaths  to  be  taken?" 

"An  evil  of  inconceivable  magnitude  and  distressing  results  in  the  working 
and  present  condition  of  this  institution,  has  been  the  introduction  into  it  of 
criminal  lunatics.  *  *  *  It  is  an  outrage  against  public  benevolence,  and 
an  indignity  to  human  affliction,  to  cast  into  the  same  house  of  refuge  with  the 
harmless,  feeble,  kind-hearted,  and  truthful  victims  of  ordinary  insanity,  those 
moral  monsters  which  nature  seems  sometimes  to  have  formed  for  the  purpose 
of  teaching  us  the  inestimable  value  of  the  constitution  with  which  the  species 
has  been  blessed ;  or,  yet  worse,  those  villains  who  affect  insanity  as  a  means 
of  evading  the  just  punishment  of  the  most  atrocious  crimes."  (Report  for 
1853-4.) 

Another  home-thrust,  equally  effective  with  one  already  mentioned.  The 
criminal  patients  were  soon  afterwards  removed  to  Kingston.  The  hardiesse 
with  which  the  pen  of  the  author  of  these  reports  grapples  with  evil  is  truly 
refreshing. 

2.  Before  the  year  1836,  there  was  no  receptacle  exclusively  devoted  to  the 
insane  in  the  Province  of  New  Brunswick.  The  pauper  insane  were  sometimes 
confined  in  almshouses  or  gaols,  and  patients  for  whom  restorative  treatment 
was  desired,  were  sent  by  their  friends  to  foreign  hospitals — generally  to  those 
in  the  United  States.  In  the  year  mentioned,  a  building  in  the  city  of  St.  John 
was  opened  as  a  "  Provisional  Lunatic  Asylum."  It  was  chiefly  intended  for 
the  indigent  insane  of  the  Province ;  and  it  received  liberal  grants  from  the 
public  funds,  towards  its  current  expenses.  After  the  lapse  of  about  ten  years, 
the  necessity  for  enlarged  accommodations  having  become  urgent,  an  effort  for 
the  foundation  and  erection  of  a  provincial  hospital  was  successfully  made.  A 
farm  of  forty  acres,  on  the  west  side  of  the  harbor  of  St.  John,  was  purchased, 
buildings  erected  thereupon,  and  the  establishment  opened  for  the  reception  of 
patients  on  the  12th  of  December,  1848. 

The  number  of  patients  annually  received  at  the  provisional  asylum  varied 
from  29  to  73,  the  total  for  the  thirteen  years  from  1836  to  1848,  inclusive,  being 
652.  The  reports  before  us  give  no  information  in  regard  to  the  number  of 
cures  or  deaths.  Ninety  patients  remained  in  December,  1848,  and  these  were 
transferred  to  the  new  hospital. 


1863.]  Institutions  for  Insane  in  the  British  American  Provinces,  439 


The  edifice  of  the  Provincial  Lunatic  Asylum  of  New  Brunswick  is  con- 
structed of  brick.  It  consists  of  "a  main  centre  building,  and  four  corner 
buildings,  three  stories  each,  and  four  connecting  wings,  two  stories,  with  a 
high  two  story  erection,  extending  back  from  the  centre,  80  by  26  feet.  This 
back  centre  erection  includes  the  washing  department,  in  the  basement,  the 
kitchen,  &c,  on  the  first  flat,  and  the  chapel  on  the  second  flat." 

In  December,-  1849,  Dr.  John  Waddell  was  appointed  superintendent.  He 
still  continues  in  the  office,  the  duties  of  which  he  has  performed  with  much 
ability  and  practical  skill. 

The  number  of  patients  annually  admitted  has  varied  from  48  to  108.  The 
whole  number,  from  the  12th  of  December,  1848,  to  the  31st  of  October,  1861, 
including  the  90  transferred  from  the  provisional  asylum,  is  1147. 

Discharged,  cured  462 


In  the  report  for  1858,  it  is  stated  that,  of  the  cases  discharged  recovered,  8 
were  of  delirium  tremens. 

The  reports  of  Dr.  Waddell  are  very  brief,  and,  aside  from  statistics,  confined 
almost  exclusively  to  the  material  and  financial  departments  of  the  institution. 
We  gather,  however,  a  few  extracts  of  a  more  professional  type. 

"As  a  general  rule,  insanity  depends  upon  an  atonic  condition  of  the  system, 
and  in  many  of  these  cases  there  is  great  excitement ;  and  if  treatment  is  based 
on  the  erroneous  idea  (as  it  sometimes  is)  that  by  lowering  the  system  the 
excitement  will  cease,  incalculable  mischief  may  be  done.  Every  step  in  such 
a  course  increases  the  violence  of  the  symptoms,  and,  if  persisted  in,  the  patient 
will  either  sink  from  exhaustion  in  the  acute  stage,  or,  if  he  possess  vital  powers 
sufficient  to  resist  the  evil  effect  of  such  treatment,  it  is,  in  many  cases,  but  to 
decline  into  a  state  of  hopeless  imbecility."    (Report  for  1859.) 

"  I  am  convinced  that  useful  employment,  especially  in  the  open  air,  judici- 
ously adapted  to  the  strength,  and  in  harmony  with  the  feelings  of  self-respect, 
has  exerted  a  powerful  influence  in  promoting  the  health,  the  comfort,  and  the 
happiness  of  those  under  my  charge. 

"  The  institution  continues  to  be  the  resort  of  all  classes.  I  am  not  aware  of 
there  being  any  insane  persons  provided  for  in  any  other  way  in  the  Province, 
nor  do  I  know  of  any  dangerous  or  troublesome  persons  being  at  large.  The 
care  and  treatment  of  the  insane  seem  to  be  entirely  accomplished  by  the 
institution. 

"There  seems  to  be  no  alarming  increase  of  mental  disease  in  the  Province ; 
none  beyond  what  is  natural  with  the  ordinary  increase  of  population.  The 
people  being  thinly  scattered  over  a  large  and  rich  territory,  where  every  facility 
exists  to  procure  the  comforts  of  life  without  that  strife  and  exhausting  toil  so 
common  in  older  and  more  thickly  peopled  lands,  are  necessarily  exempt  from 
a  large  class  of  influences  that  tend  to  develop  insanity.  I  may  mention,  too, 
what  appears  to  be  a  fact,  that  the  popular  element  of  this  Province  is  seldom 
seriously  disturbed.  Political  revolutions,  which  seem  to  convulse  other  com- 
munities all  around,  produce  but  a  very  transitory  effect  here,  and,  while  the 
land  is  productive  of  everything  that  is  good  for  the  sustenance  of  its  inhabi- 
tants, when  properly  cultivated,  it  is  a  soil  in  which  spiritualism,  and  all  other 
such  isms — so  prolific  of  insanity — do  not  flourish."    [Report  for  1860.) 

Yes,  and  that  last  remark  would  doubtless  apply  to  Greenland  or  to  Pata- 
gonia, as  well  as  to  New  Brunswick.  The  reviewer  is  not  an  advocate  of 
"  spiritualism,"  but  he  has  some  love  for  scientific  investigation.  He  would, 
therefore,  like  to  ask  whether  the  ordinary  forms  of  the  Protestant  religion — 
"  so  prolific  of  insanity" — see  the  hospital  reports  for  the  proof  of  the  fact — 
"flourish"  in  the  soil  of  New  Brunswick? 

The  reports  contain  nothing  by  which  we  are  enabled  to  form  an  estimate, 
either  actual  or  comparative,  of  the  facilities  or  means  for  moral  treatment  pos- 
sessed by  the  institution.  It  is  stated  that  religious  services  are  performed  on 
the  Sabbath,  and  that  newspapers  "  are  much  valued  by  the  patients." 


Died 
Remaining 


244 
168 


440 


Bibliographical  Notices. 


[April 


3.  In  1845,  three  commissioners  from  Nova  Scotia  visited  many  of  the  hos- 
pitals for  the  insane  in  the  United  States,  for  the  purpose  of  making  investiga- 
tions and  observations  preliminary  to  the  foundation  of  a  similar  institution  in 
the  aforesaid  province.  For  several  years  afterwards  no  very  active  measures 
were  taken  for  the  prosecution  of  the  enterprise ;  but  private  donations  and 
legislative  appropriations  therefor  were  made  from  time  to  time,  and  at  length 
a  farm  of  85  acres,  "on  the  Dartmouth  side  of  the  harbor  of  Halifax,  at  a  dis- 
tance of  about  two  miles  from  the  city,"  was  selected  by  Miss  D.  L.  Dix,  as  an 
appropriate  site,  and  purchased  accordingly. 

The  plan  adopted  for  the  building  is  that  of  the  United  States  Government 
Hospital  for  the  Insane,  near  Washington,  D.  0.  This  plan  has  been  described 
in  our  former  notices  of  reports. 

The  corner-stone  of  the  hospital  was  laid  on  the  8th  of  June,  1856.  A  part 
of  one  wing  having  been  completed,  the  hospital  was  opened,  under  the  charge 
of  Dr.  James  R.  DeWolf,  and  the  first  patient  received  on  the  26th  of  Decem- 
ber, 1858.  The  general  statistics  from  that  date  to  the  31st  of  December,  1861, 
are  as  follows  : — 


Patients  admitted  ,      .       .  193 

Discharged   76 

Remaining,  at  the  close  of  1861   117 

Of  the  patients  discharged,  there  were  cured     ....  37 

Died   14 


The  whole  wing  was  finished  in  1861,  but  neither  the  central  edifice  nor  the 
other  wing  has  been  begun.  Meanwhile  the  superintendent,  with  overcrowded 
halls,  is  pleading  for  further  accommodations. 

"According  to  the  census  of  1861,  there  are,  in  Nova  Scotia,  340  insane  per- 
sons, or  rather  more  than  one  in  a  thousand  of  the  entire  population.  Of  this 
number,  223,  or  nearly  two-thirds  of  the  whole,  remain  without  the  advantages 
of  hospital  care,  many  of  them  wandering  about — even  in  this  inclement  season 
— others  confined  mercilessly,  and  all  so  situated  as  to  demand  our  warmest 
sympathy."    {Report  for  1861.) 

"A  fair  proportion  of  the  wealthier  classes  continue  to  avail  themselves  of  the 
hospital  for  the  care  and  cure  of  their  friends.  The  money  hitherto  sent  abroad 
to  maintain  this  class  of  patients  in  foreign  institutions,  is  now  expended  within 
our  own  borders."  (1861.) 

Here  is  a  case  of  the  use  of  an  anaesthetic  for  a  novel  purpose  : — 

"A  young  female  patient  who  had  not  spoken  for  months,  gradually  desisted 
from  eating,  and  it  was  with  the  greatest  difficulty  that  her  mouth  could  be 
opened.  It  was  only  under  the  relaxing  influence  of  chloroform  that  the  rigidity 
of  the  jaws  could  be  overcome.  The  patient  for  upwards  of  three  months  swal- 
lowed no  food  voluntarily.  Twice,  daily,  was  the  feeding  pump  resorted  to.  At 
last  she  was  induced  to  drink  a  little,  then  a  little  more,  then  took  soft  food,  and 
now  eats  heartily  of  the  ordinary  diet.  She  has  grown  quite  fleshy  of  late,  and 
is  happily  beginning  to  speak."    {Report  for  1860.) 

We  cull  a  few  extracts  in  regard  to  moral  treatment : — 

"The  industrious  patients  are  encouraged  by  small  gratuities;  but  it  is  not  in 
our  power  to  carry  out  this  principle  to  the  extent  its  importance  deserves.  It 
would  be  only  just  and  fair  to  recompense  the  labour  of  quiet,  industrious  pa- 
tients, either  by  periodical  money  payments,  or  by  allowing  their  earnings  to 
accumulate,  and  paying  them  the  interest  of  this  sum  annually,  should  they 
become  able  to  leave  the  hospital."  (1861.) 

"The  restoration  of  the  insane  being  the  primary  object  of  the  institution, 
labour  must  be  looked  upon  more  in  a  curative  than  a  pecuniary  light.  Hence 
we  find  it  requisite,  in  some  instances,  to  check  the  eagerness  for  continued 
laborious  exertion  which  is  exhibited  by  some  patients,  and  so  to  apportion  the 
work  that  all  who  engage  in  it  may  be,benefited  by  what  they  do."  (1860.) 

"  In  order  to  carry  out  effectually  the  modern  humane  system  of  non-restraint, 
so  ably  advocated  by  Dr.  Conolly,  we  have  aimed  from  the  first  to  engage  the 
services  of  active,  cheerful  and  trustworthy  attendants,  and  have  instructed 
them  in  their  arduous  and  responsible  duties.    In  one  instance  we  combated 


1863.] 


Wilson,  Diseases  of  the  Skin. 


441 


the  determined  self-injury  of  a  patient  who  had  a  habit  of  beating  his  head 
with  increasing  violence  against  the  wall.  We  fitted  up,  for  this  man,  a  "  padded 
room,"  by  means  of  which  he  has  enjoyed  a  freedom  of  motion,  and  an  amount 
of  liberty,  which  could  in  no  other  way  be  accorded  to  him. 

"Cases  of  extreme  destructiveness  occasionally  arise,  setting  all  ordinary 
care  utterly  at  defiance.  One  such  we  had  recently,  when  the  constant  pre- 
sence, by  day  and  by  night,  of  one,  generally  two,  and  often  three  attendants, 
was  insufficient  to  prevent  the  destruction  of  property  and  the  serious  disturb- 
ance of  the  other  patients.  The  propensity  was  at  last  overcome  by  continued 
kindness,  and  by  a  determined  refusal  to  sanction  the  application  of  any  restrain- 
ing apparatus."  (1861.) 

We  do  not  perceive  how  the  refusal  to  apply  mechanical  restraint  assisted  in 
overcoming  the  fury  of  the  patient,  unless  he  feigned  his  fury  for  the  sole  pur- 
pose of  being  placed  under  such  restraint.  Although  we  are  in  favour  of 
reducing  restraint  to  its  wholesome  minimum,  and,  as  early  as  1845  and  1846, 
did,  as  we  believe,  reduce  it  to  a  lower  amount  than  had  ever  theretofore  been 
attained  on  this  side  of  the  Atlantic,  yet  we  must  candidly  avow  our  belief  that 
the  above  case  was  badly  treated.  We  think  that  less  evil  would  have  arisen 
to  the  patient  himself,  if  he  had  been  placed,  alone,  in  a  vacant  room,  with 
his  hands  securely  and  comfortably  (for  that  can  be  done)  confined  by  a  strong 
camisole. 

There  are  many  patients  who,  if  they  were  placed  under  the  surveillance  of 
three  special  attendants,  would  continue  their  violence  (when  otherwise  it  would 
have  subsided)  through  irritation  or  anger,  or  from  "spite,"  or,  if  from  neither 
of  these  causes,  then  merely  "for  the  fun  of  the  thing,"  and  to  show  those 
attendants,  as  Sam.  Patch,  when  he  was  about  to  leap  from  the  cataract,  said 
that  he  wished  to  show  the  world,  that  "  some  things  can  be  done  as  well  as 
others." 

"Excursions  to  the  country  in  summer,  sleigh-drives  in  the  winter,  visits  to 
interesting  exhibitions  in  the  city  occasionally,  and  attendance  at  the  village 
church  on  Sundays,  have,  during  the  past  year,  relieved  the  tedium  of  daily 
routine."  (1861.) 

A  billiard  table,  a  piano  forte,  books,  engravings,  &c,  have  been  presented  to 
the  institution  ;  and  by  a  sum  raised  by  subscription,  bagatelle,  back-gammon, 
and  draught-boards,  footballs,  pictures  and  toys,  have  been  purchased.  The  list 
of  "  acknowledgments"  is  long  in  each  of  the  last  reports,  and  hence  we  con- 
clude that  the  Nova  Scotia  Hospital  for  the  Insane  is,  as  it  ought  to  be,  a  centre 
of  popular  interest  and  sympathy.  P.  E. 


Art.  XXI V.— On  Diseases  of  the  Skin.  By  Erasmus  Wilson,  F.  E.  S.  Fifth 
American  from  the  fifth  and  revised  London  edition.  With  plates  and  illus- 
trations on  wood.    Philadelphia  :  Blanchard  &  Lea,  1863.    8vo.  pp.  694. 

A  review  of  the  fourth  edition  of  this  work  was  given  in  the  number  of  this 
Journal  for  October,  1857.  The  peculiarities  of  the  treatise  of  Mr.  Wilson  on 
diseases  of  the  skin,  which  render  it  far  superior  to  any  other  in  the  English 
language,  are  there  carefully  and  fully  pointed  out  and  commented  upon.  We 
believe,  however,  that  the  great  value  of  the  work,  and  the  additions  made  to 
the  present  edition,  call  for  something  more  on  the  present  occasion  than  the 
simple  announcement  of  the  appearance  of  a  new  edition,  and  the  mere  indica- 
tion of  the  points  in  which  this  volume  differs  from  its  predecessor. 

Mr.  Wilson's  treatise  is  not  simply  what  its  title  indicates ;  that  is,  if  we  are 
to  judge  from  what  is  generally  contained  in  works  bearing  the  title  on  "  Diseases 
of  the  Skin."  It  contains  a  great  deal  more  than  a  detailed  description  of  the 
vesicular,  papular,  pustular,  and  other  eruptive  affections  that  are  witnessed  on 
the  external  covering  of  the  body.  As  distinguishing  it  from  all  others  it  might 
be  styled  a  treatise  on  the  skin  and  its  appendages,  the  hair  and  the  nails,  and 


442 


Bibliographical  Notices. 


[April 


the  sudoriparous  and  sebiparous  glands,  their  normal  and  pathological  anatomy 
and  physiology;  with  an  account  of  their  diseases  and  of  the  affections  in  which 
a  disorder  of  these  parts  is  a  prominent  symptom,  together  with  their  proper 
treatment. 

Owing  to  the  manner  in  which  they  are  always  treated  of  in  medical  writings, 
diseases  of  the  skin  bear  about  the  same  relation  to  other  groups  of  disease, 
that  the  irregular  verbs  in  a  grammar  bear  to  the  regular  conjugations.  As  dis- 
connected, unlike  all  others,  and  difficult  to  remember,  their  study  is  universally 
disliked.  From  the  way,  however,  in  which  the  whole  subject  has  been  compre- 
hended by  Mr.  Wilson,  skin  diseases  are,  so  to  speak,  regularized,  and  their 
study  in  the  work  before  us  is  anything  but  disagreeable.  Indeed,  it  can  be 
said  with  truth,  that  so  readable  and  so  satisfactory  a  medical  work  is  rarely 
met  with. 

After  an  excellent  account  of  the  anatomy  and  physiology  of  the  skin,  the 
sudoriparous  and  the  sebiparous  systems,  and  the  hairs  and  nails,  Mr.  Wilson, 
in  a  separate  chapter,  enters  upon  the  subject  of  the  classification  of  diseases 
of  skin,  and  exposes  in  a  way  that  cannot  be  too  much  admired  the  manner  in 
which  such  a  classification  should  be  conducted. 

Li  ceil  ne  voit  pas  ce  qui  le  touche,  '  the  eye  does  not  see  the  object  that  touches 
it,'  is  a  favourite  maxim  which  maybe  applied  on  this  occasion,  where,  precisely 
because  diseases  are  directly  visible  immediately  under  the  eye,  we  do  not  judge 
of  them  correctly.  It  is  from  classifying  diseases  to  which  the  skin  is  subject, 
almost  entirely  according  to  what  is  told  of  them  by  the  eye,  that  so  little  prac- 
tical benefit  results.  For  example,  on  the  scalp  true  papulae  are  never  seen,  and 
vesicles  very  rarely.  On  the  hands,  and  especially  the  fingers,  vesicles  and  pus- 
tules are  frequent ;  but  on  the  rest  of  the  surface  of  the  body  lichen  is  the 
common  type.  So  that,  in  a  general  eruption,  produced  by  one  and  the  same 
cause,  occurring  upon  the  entire  surface  of  the  body,  we  would  have  erythema 
in  one  part,  lichen  in  another,  eczema  in  a  third,  possibly  impetigo  in  a  fourth, 
and  psoriasis  in  a  fifth.  Now  if  we  should  follow  the  generality  of  treatises  on 
diseases  of  the  skin  in  presence  of  such  a  case,  we  would  see  here  five  different 
and  distinct  complaints  belonging  to  five  different  orders  of  disease,  and  possibly 
think  it  necessary,  in  order  to  follow  what  we  have  read  as  to  the  proper  course 
to  pursue,  to  prescribe  five  different  modes  of  treatment.  In  a  practical  point 
of  view,  and  taking  other  things  into  consideration  besides  what  we  can  see, 
there  is  here  but  one  disease,  an  inflammatory  eruption,  exhibiting  in  various 
parts  of  the  body  the  five  usual  modes  of  manifestation  of  cutaneous  inflamma- 
tion, and  all  amenable  to  the  same  treatment.  For  practical  purposes,  diseases 
of  the  skin  should  be  arranged  according  to  their  causes ;  the  classification 
should  be  etiological.  To  convince  any  one  who  may  be  at  all  skeptical  on  this 
point,  we  cannot  do  better  than  to  refer  him  to  the  chapter  on  classification  in 
the  volume  before  us,  and  also  to  the  two  succeeding  chapters  in  the  general 
pathology  and  the  general  therapeutics  of  the  skin. 

The  present  volume  differs  from  that  of  the  preceding  American  edition  prin- 
cipally in  containing  a  number  of  plates  illustrating  the  anatomy  of  the  skin  and 
its  appendages,  and  the  various  cutaneous  diseases  comprising  those  prepared 
by  Mr.  Wilson  to  illustrate  his  work  on  constitutional  syphilis  and  syphilitic 
eruptions.  The  whole  getting  up  of  the  volume  is  as  perfect  as  possible,  and 
we  take  unusual  pleasure  in  announcing  its  presentation  to  the  profession  in 
this  country.  There  are  very  few  medical  works  which  its  members  generally 
can  have  so  much  reason  to  desire  to  possess.  By  it  the  treatment  of  a  badly 
taught  and  neglected  class  of  diseases,  that  are  the  cause  of  very  considerable 
suffering  and  annoyance  to  their  patients,  is  rendered  simple  and  rational,  and 
removed  from  the  special  and  isolated  position  which  they  at  present  occupy  into 
the  general  category  of  diseases  of  the  human  frame.   '  W.  F.  A. 


1863.]        Bouchard  at,  Therapeutics  and  Materia  Medica.  443 


Art.  XXY. — Annuaire  de  Thirapeutique,  de  Matiere  MSdicale,  de  Phar- 
macie  et  de  Toxicologie,  pour  1862,  Sec.  Par  A.  Bouchard  at,  Prof.  d'Hygiene 
de  la  Faculty  de  Medecine  de  Paris,  &c.    22  Annee :  Paris. 

The  number  of  the  "  Annuaire"  for  1862,  by  the  distinguished  pharmacologist, 
Bouchardat,  is  fully  as  interesting  as  his  former  summaries.  One  of  the  merits 
of  this  work  is  its  long-continued  publication,  which  gives  it  the  importance 
of  an  extensive  serial.  It  is  especially  valuable  as  a  record  for  many  years 
of  the  advance  and  progress  of  discovery  in  the  branch  to  which  it  is  devoted, 
and  must  now  be  considered  as  a  necessary  portion  of  the  library  of  the  inquiring 
pharmaceutist  and  therapeutist.  In  our  last  notice  for  1861,  a  reference  was 
made  to  the  history  of  this  standard  periodical,  and  we  believe  that  a  summary 
of  the  contents  of  the  present  issue  cannot  be  otherwise  than  acceptable  to  the 
readers  of  the  Journal. 

Under  the  head  of  "Narcotics,"  the  first  article  is  devoted  to  the  considera- 
tion of  the  therapeutics  of  poisoning  by  morphia  and  the  medicines  containing 
it,  with  a  note  of  some  reflections  upon  the  detection  of  morphia  in  the  urine. 
At  the  commencement  of  his  remarks  under  this  title,  M.  Bouchardat  states 
that  it  is  surprising  that  he  has  not  previously  published  his  views,  particularly 
as  he  has  dwelt  fully  upon  the  subject  in  his  lectures,  in  which  he  maintains  that, 
after  the  primary  stimulant  impression  upon  the  nervous  system,  which  assimi- 
lates morphia  to  caffein,  has  subsided,  the  depressing  effect  occurs,  the  most 
prominent  manifestation  of  which  is  sleep.  This  latter  impression  is  confined 
at  first  to  the  functions  of  relation,  and  the  sleep  resembles  that  of  a  physiolo- 
gical kind;  but  if  the  dose  be  larger,  "the  sleep"  extends  to  the  apparatus  of 
nutrition,  or  organic  life.  The  functions  of  respiration  and  circulation  belong 
to  the  latter  series,  and  should  never  sleep.  If  sleep  invades  these  functions, 
life  becomes  extinguished,  and  this  is  precisely  the  mechanism  of  poisoning  by 
opiates.  It  is  ordinarily  from  six  to  eight  hours  that  the  general  sleep  occurs 
after  the  ingestion  of  the  opiate,  if  it  be  not  interfered  with ;  and  it  can  be 
readily  understood  how  poisoning  can  be  more  rapid  if  taken  at  night  when 
retiring,  than  when  taken  in  the  morning.  From  this  is  deduced  the  importance 
of  counteracting  the  first  or  physiological  sleep,  as  it  precedes  the  second,  or 
the  sleep  of  the  apparatus  of  nutrition,  and  it  is  essential  to  prevent  the  patient 
from  falling  into  it  by  every  means  at  command.  As  an  antagonistic  agent  to 
this  condition,  M.  Bouchardat  recommends  the  liberal  use  of  the  strongest 
infusion  of  coffee,  and  it  is  best  to  keep  the  patient  awake  for  twelve  or  eighteen 
hours,  so  as  to  afford  ample  time  for  the  elimination  of  the  morphia  by  the  kid- 
neys. The  determination  of  this  fact  is  to  be  effected  by  the  appropriate  test. 
The  test  proposed  is  essentially  the  same  as  for  quinia  and  other  alkaloids,  viz., 
the  iodo-iodide  of  potassium,  made  after  the  following  formula :  Take  of  iodine 
giiss,  of  iodide  of  potassium  gv,  of  water  f^viij.  A  less  quantity  may  be  pre- 
pared, or  Lugol's  solution  will  answer  the  purpose.  There  need  be  no  fear  of 
employing  the  solution  in  excess.  So  long  as  the  urine  gives  brown  flocculi, 
the  morphia  has  not  been  eliminated,  and  it  is  necessary  to  keep  the  patient 
awake.  In  the  treatment  of  the  case  it  is  very  important  to  watch  the  first 
sleep,  to  be  sure  that  the  respiration  and  the  circulation  are  normal. 

With  the  adoption  of  this  mode  of  treating  poisoning  by  opium,  M.  Bouchar- 
dat at  the  same  time  looks  favourably  upon  the  employment  of  other  remedies, 
as  emetics,  if  the  poison  be  recently  taken,  for  the  double  purpose  of  emptying 
the  stomach  and  keeping  the  patient  awake.  With  respect  to  the  latter  effect 
it  may  be  doubted  whether  the  impression  of  an  emetic  is  calculated  to  promote 
wakefulness,  and,  as  depression  is  induced,  the  chance  of  absorption  may  be 
augmented.  Still  an  emetic  removes  the  substance  from  the  stomach,  and  this 
is  most  desirable. 

With  respect  to  chemical  antidotes,  abundant  evidence  is  afforded  to  render 
him  an  unhesitating  advocate  of  them.  M.  Bouchardat  does  not  enter  into  the 
consideration  of  the  newly  proposed  narcotic  antidotes,  or,  as  they  should  more 


444 


Bibliographical  Notices. 


[April 


appropriately  be  called,  the  vital  antagonistic  remedies.  From  the  whole  tenor 
of  his  reflections,  both  now  and  heretofore,  we  are  inclined  to  believe  that  he 
has  no  faith  in  their  use.  By  so  acute  an  observer  and  faithful  a  recorder  they 
cannot  have  been  overlooked. 

Physiological  Effects  of  Atropia,  and  its  Employment  in  the  Treatment  of 
Epilepsy. — A  resume  is  given  of  an  essay  published  upon  this  subject  by  M. 
Michla,  in  the  Gazette  des  Hopitaux,  as  follows :  1.  Atropia  and  its  salts  act 
principally  upon  the  cerebro-spinal  system.  2.  They  depress  or  tend  to  abolish 
the  functions  of  the  different  parts  of  the  system  successively,  and  not  simul- 
taneously. 3.  They  affect  the  motor  nervous  apparatus  before  affecting  the 
sensitive,  and  the  last  to  be  impressed  are  the  organs  of  intelligence  and  of  the 
moral  feelings,  or  the  cerebral  organs.  4.  In  the  same  way  as  attacks  of  epi- 
lepsy commence  in  the  muscles  of  the  neck  and  of  the  face,  the  paralysis  of  atropia, 
beginning  with  the  iris,  successively  proceeds  to  the  muscles  of  deglutition,  of 
phonation,  and  to  the  muscles  of  the  eye.  In  other  words,  the  organs,  which 
are  first  convulsively  attacked  in  epilepsy,  are  nearly  the  same  as  those  im- 
pressed by  atropia,  the  order  being  reversed.  5.  In  the  rational  treatment  of 
epilepsy,  atropia  is  preferable  to  curare,  which  paralyzes  exclusively  the  motor 
nerves ;  while  the  active  principle  of  belladonna  not  only  paralyzes  the  motor 
nerves,  but  also  the  sensitive  nerves,  which  are  the  seat  of  the  aura  epileptica. 
6.  In  the  class  of  Batraciens,  poisoned  by  strychnia,  after  being  previously  sub- 
mitted to  the  influence  of  valerianic  acid,  of  valerianate  of  zinc,  or  valerianate 
of  quinia,  the  convulsions  were  not  as  violent  as  when  the  impression  was  made 
exclusively  by  strychnia;  and  in  place  of  succumbing,  as  in  the  last  case,  in  a 
perfectly  rigid  state,  they  died  in  a  state  of  complete  muscular  relaxation.  7. 
In  frogs,  previously  submitted  to  the  action  of  the  oxide  of  zinc,  of  sulphate  of 
zinc,  or  the  sulphate  of  quinia,  the  convulsions  of  strychnia  are  as  intense,  or 
nearly  so,  and  their  duration  as  protracted,  as  when  these  articles  were  not  used. 
And  further,  death  occurred  in  a  tetanic  state.  8.  In  man,  certain  primary  or 
physiological  effects  of  atropia  are  produced  when  the  salts  are  employed. 
These  were  brought  about  more  rapidly,  and  from  smaller  doses,  when  the  vale- 
rianate was  employed,  than  by  the  sulphate,  a  fact  which  is  explained  by  the 
supposition  that  the  valerianic  acid  is  operative.  A  half  milligramme  (gr.  T^) 
of  the  valerianate  of  atropia  produces  often  dryness  of  the  throat  and  dilata- 
tion of  the  pupils  the  day  after  its  exhibition ;  whilst,  generally,  it  is  hardly  on 
the  day  after  the  next,  and  in  the  dose  of  1  milligramme  (gr.  ^)  that,  the  sul- 
phate produces  the  same  phenomena.  Therapeutically  less  valerianate  of  atropia, 
than  of  the  sulphate,  is  required  to  modify  the  access  of  epilepsy,  or  to  post- 
pone its  return,  or  weaken  its  violence.  This  result,  according  to  the  author,  is 
often  obtained  without  exceeding  the  dose  of  (in  all)  2  milligrammes,  or  gr. 
provided  the  use  of  the  medicine,  interrupted  from  time  to  time,  is  sufficiently 
continued.  In  fact,  in  the  treatment  of  epilepsy,  the  practice  is  to  give  vale- 
rianate of  atropia  in  the  dose  of  a  half  milligramme  every  twenty-four  hours, 
and  never  exceed  2  milligrammes.  9.  In  consequence  of  the  state  of  hyperes- 
thesia of  the  skin,  either  general  or  partial,  existing  in  epileptics,  it  is  necessary 
in  the  treatment  to  take  care  to  avoid  all  exciting  impressions  on  the  surface 
capable  of  producing  reflex  action,  and  particularly  electrical  excitement  and 
cold  in  the  form  of  lavation  or  bathing.  With  reference  to  the  foregoing  treat- 
ment, M.  Bouchardat  informs  us  that  he  agrees  with  M.  Michea  in  two  points ; 
the  first  is  to  commence  the  dose  with  a  £  milligramme,  and  never  to  exceed  2 
milligrammes ;  the  second  is  to  suspend  the  employment  of  the  medicine  on  the 
occurrence  of  disturbance  of  vision. 

Contrary  to  the  opinion  of  M.  Michea,  he  believes  that  crystallizable  atropia, 
which  is  soluble  in  the  gastric  juice,  is  preferable  to  all  the  salts  of  which  it 
is  the  base.  He  reminds  the  reader  that  he  and  Stuart  Cooper  first  introduced 
atropia  into  therapeutics,  and  that  he  himself  first  prescribed  it  in  epilepsy. — 
Annuaire,  1848. 

The  following  is  a  liniment  of  belladonna:  Take  of  extract  of  belladonna  and 
of  glycerine  each  two  drachms  and  a  half,  and  mix  intimately.  Use  as  an  em- 
brocation upon  the  breast,  then  cover  the  part  with  taffeta.  It  is  intended  to 
check  the  flow  of  milk  and  to  prevent  abscess. 


1863.]        B  ouc  hard  at,  Therapeutics  and  Materia  Medica.  445 


Effects  of  Tobacco. — Dr.  B.  W.  Richardson  has  made  some  interesting  re- 
marks from  the  observation  of  a  large  number  of  smokers.  In  the  morning 
before  smoking  the  blood  of  a  great  smoker  is  in  a  normal  condition ;  in  the 
evening  after  smoking  fifteen  or  twenty  pipes,  the  blood  becomes  abnormal ;  the 
central  point,  that  is,  the  central  depression  of  the  blood-corpuscles  is  not  visi- 
ble, and  the  drops  of  blood  coagulate  without  drying,  which  occurs  when  taken 
upon  the  person  awakening  in  the  morning.  After  a  tranquil  night  of  sleep  the 
morbid  phenomenon  referred  to  disappears.  The  inhalation  of  air  charged  with 
ammonia  has  the  same  effect  upon  the  globules  of  blood  as  the  smoke  of  tobacco. 
The  author  moreover  remarks,  that  the  breath  of  smokers  is  always  more  or 
less  ammoniacal. 

Poisoning  by  the  Berries  of  the  Solatium  Pseudo-Capsicum.- — From  the 
Journal  M.6d.  de  Bordeaux  are  taken  two  interesting  cases  which  illustrate 
the  poisonous  influence  of  the  berries  of  the  plants  pertaining  to  the  genus 
Solarium.  The  one  referred  to  has  been  introduced  into  Europe  and  this  country 
from  South  America.  It  has  been  called  the  S.  montanum  and  S.  Valenzualae, 
D.  C.  It  resembles  the  bird's-eye  pepper  both  in  the  leaves  and  berries.  From 
the  resemblance  to  the  latter  it  has  the  first  mentioned  designation.  A  child 
of  five  years  of  age  died  at  Moissac  from  eating  the  berries  of  this  plant,  and 
another  child  of  four  years  was  seriously  affected  by  them.  Three  or  four 
berries  are  sufficient  to  produce  poisonous  effects  of  serious  import,  such  as 
nausea  and  vomiting,  somnolence,  acute  hypogastric  pain,  dilatation  of  the 
pupil,  &c.  In  the  latter  case  free  vomiting,  the  application  of  mustard  plasters, 
and  the  administration  of  coffee,  affording  relief. 

The  berries  of  the  Solarium  dulcamara  are  productive  of  the  same  results. 
A  case  of  death  is  recorded  in  the  Revue  Mddico-Chirurgicale,  from  the  latter. 
These  cases  bring  to  mind  one  which  occurred  to  the  late  Dr.  Isaac  Parrish,  of 
this  city.  Symptoms  of  narcotic  poisoning  were  present  but  not  accounted  for 
until  autopsy  revealed  the  cause  in  the  stomach. 

Chloroform  and  Ether. — It  appears  that  the  cases  of  death  from  chloroform 
are  more  numerous  this  year  than  in  preceding  years.  Perhaps  it  may  be  that 
the  medical  press  has  registered  them  with  more  care  than  previously.  M. 
Bouchardat  states,  that  he  accords  with  the  opinion  of  the  editor  of  U  Union 
Me'dicale,  in  thinking  that  "  Chloroform  has  so  great  a  power  for  good  or  for 
evil  that  all  that  tends  to  preserve  the  good  and  diminish  the  bad  ought  to  be 
recorded  with  the  greatest  care."  The  following  facts  are  presented  by  the  last 
year's  experience:  M.  Yigneron  has  presented  an  experimental  work,  which 
establishes  the  fact  clearly,  that  the  pain  of  the  operation  favours  the  syncope 
produced  by  the  chloroform.  M.  Am.  Forget  endorses  this  in  the  following 
terms:  "In  the  presence  of  these  facts,  confirmed  equally  by  clinical  observa- 
tion and  experimental  teaching,  and  which  concur  in  establishing  that  where 
the  traumatic  impression  alone  is  acute,  yet  fugacious  and  transient,  the  inter- 
vention of  anaesthesia  by  chloroform  renders  this  impression  persistent  and  pro- 
found, perhaps  mortal.  In  the  presence  of  these  facts,  I  say,  who  will  not  be  led 
to  demand,  if  the  remedy  for  an  evil  inherent  to  humanity,  that  is  for  physical  pain, 
is  not  worse  than  the  evil  itself?"  M.  Forget  excludes  from  this  view  of  anaes- 
thetics the  employment  of  ether,  of  which  he  says  that  this  article  which  pre- 
ceded the  employment  of  chloroform,  and  whose  abandonment  was  justified  by 
no  sufficient  motive,  is  far  from  being  as  dangerous.  It  is  capable  of  fulfilling 
all  the  indications  required  of  it.  The  surgeons  of  Lyons  have  never  abandoned 
the  employment  of  ether,  and  they  have  been  justified  in  giving  to  it  the  prefer- 
ence ;  for  it  is  but  exceptionally  that  the  ultra  partisans  of  chloroform  have  been 
able  to  oppose  to  their  opinion  and  practice,  which  has  now  continued  nearly 
twenty  years,  some  rare  examples  of  accidents  of  a  serious  nature,  and  then  at 
the  commencement  of  its  use,  and  which  have  not  been  interpreted  with  perfectly 
irreproachable  accuracy. 

A  memoir  before  the  Chirurgical  Society  of  Paris,  by  Dr.  Ernest  Berchon, 
has  for  its  object  the  direction  of  attention  on  the  part  of  surgeons  to  the  me- 
thodical employment  of  anaesthetics,  and  especially  of  chloroform.  It  has  for 
its  foundation  an  immense  number  of  facts,  collected  since  1849,  in  the  hospitals 


446 


Bibliographical  Notices 


[April 


of  the  Military  Marine,  on  board  the  transports  in  the  Crimea,  in  Italy,  and  in 
the  naval  stations  and  colonies. 

It  contains  296  observations  derived  from  the  clinical  wards  of  surgery,  mostly 
of  Brest  and  Toulon,  and  the  author  has  limited  himself  to  the  clinical  demon- 
stration that  if  the  anaesthetic  be  properly  administered,  as  is  the  case  in  the 
marine  service,  no  accident  will  occur.  This  result,  sufficiently  remarkable  to 
be  noted,  is  due  to  the  rules  invariably  adhered  to.  These  rules  consist  princi- 
pally, in  the  use  of  chloroform  chemically  pure;  in  the  limitation  of  the  dose 
to  an  exact  quantity,  which  should  not  exceed  10  grammes  (154  grains),  and  in 
the  employment  of  an  apparatus  which  is  very  simple  and  does  not  impede  ex- 
ternal respiration.  The  apparatus  is  a  cone  of  pasteboard  with  a  diaphragm  of 
gauze.  In  the  greatest  number  of  cases  two  or  three  minutes  suffice  to  bring  on 
profound  insensibility,  whatever  may  be  the  age,  the  occupation,  or  other  indi- 
vidual conditions  of  the  patients. 

Anaesthesia,  thus  rapidly  produced,  is  kept  up  wonderfully  to  the  termination 
of  the  most  varied  operations,  and  it  is  rare  to  be  obliged  to  administer  the 
second  dose,  of  five  grammes,  to  keep  up  the  effect. 

The  study  of  the  symptoms  of  the  ordinary  periods  of  inhalation  is  also  entered 
upon  in  this  memoir,  as  well  as  successive  discussions  upon  anaesthetic  agents 
that  took  place  either  at  the  Academy  of  Medicine,  in  1849  and  in  1857,  or  at 
the  Surgical  Society,  in  1853. 

The  enumeration  of  clinical  and  chemical  means  proper  to  ascertain  the 
purity  of  chloroform,  and  the  employment  of  measures  calculate^  to  combat  the 
accidents  attendant  upon  inhalations,  complete  this  work,  which  is  pronounced 
to  be  one  of  the  most  useful  and  perfect  to  which  the  practice  of  anaesthesia  has 
given  rise.  The  absolute  innoxiousness  of  the  method  since  1849,  ought  natur- 
ally to  attract  attention  in  the  face  of  recent  misfortunes.  It  shows  that  the 
fears  put  forth  on  the  subject  of  chloroform  are,  at  least,  exaggerated. 

Vomiting  produced  by  Chloroform,  and  Means  of  'preventing  it. — We  are 
informed  by  Dr.  Fisher  that  vomiting  is  one  of  the  complications  produced  by 
chloroform ;  to  be  apprehended  because  it  can  induce  asphyxia  and  syncope. 
He  recommends  that  a  glass  of  wine  be  administered  to  the  patient,  from  fifteen 
to  twenty  minutes  before  the  inhalation,  in  order  to  guard  against  the  occur- 
rence. 

Chloroform  in  the  Treatment  of  Biliary  Calculi,  is  recommended  by  M.  Bou- 
chardat,  on  the  principle  of  dissolving  the  cholesterine  of  these  bodies.  It  may 
be  used  as  a  substitute  for  ether.  For  the  internal  administration  of  chloroform 
a  formula  is  offered,  as  follows :  1  gramme  of  chloroform  and  8  grammes  of 
alcohol,  given  in  wine,  water,  or  syrup.  The  rule  to  be  followed  is  1  part  to  8, 
and  in  administering  a  larger  quantity  than  directed  by  the  formula,  this  is  to  be 
observed.  The  mixture  with  syrup  gives  a  perfectly  stable  preparation,  capable 
of  preservation  for  several  months  without  alteration.  With  wine  the  flavour 
is  improved. 

New  Local  Anaesthetic  Agent. — M.  A.  Claisse  recommends,  when  minor  opera- 
tions are  to  be  performed,  to  apply  or  rub  upon  the  part  a  strong  solution  of 
camphor  in  ether ;  the  application  is  to  be  continued  for  a  minute  or  two  before 
the  incision  is  made.  In  this  way  the  pain  is  lessened  when  an  abscess  is 
opened,  &c. 

Under  the  head  of  stimulants  is  a  summary  of  the  effects  of  coca,  which  was 
published  in  L'Echo  Medical  Suisse,  and  which  contains  the  following  conclu- 
sions: 1.  In  small  doses  coca  produces  a  local  action,  consisting  in  a  passing 
augmentation  of  the  salivary  secretion,  followed  by  dryness  of  the  throat  and  a 
feeling  of  warmth  in  the  epigastrium ;  moreover,  it  has  a  tonic  property,  which 
supports  under  fatigue.  2.  In  larger  doses  coca  acts  as  a  special  narcotic.  The 
most  marked  effects  are  general  ease  and  comfort,  intellectual  and  corporeal 
composure,  and  reduction  of  the  pulse.  In  very  high  doses  it  additionally  in- 
duces dilatation  of  the  pupils.  It  is  now  known  that  this  article  is  the  leaf  of 
the  Ilex  paraguayensis,  and,  according  to  Stahlschmidt,  it  contains  cafein  or 
thein.    The  Bolivean  article  owes  its  properties  to  an  alkaloid. 

Physiological  and  Therapeutical  Effects  of  Digitalis. — Under  this  head  we 
have  the  conclusions  that  have  been  reached  by  Pfaff  and  Germain  : — 


1863.] 


Bouchardat,  Therapeutics  and  Materia  Medica, 


447 


1.  That  in  contradiction  to  the  opinion  of  Saunders,  which  is  in  opposition 
to  all  that  has  been  observed  before  and  since,  digitalis  diminishes  the  frequency 
of  the  contractions  of  the  heart. 

2.  It  is  not  demonstrated  that  it  weakens  the  force  of  the  contractions  of  the 
heart,  whilst  the  theory  and  experiments  of  physiologists,  as  well  as  M.  Ger- 
main's own  experience,  prove  that  one  of  the  effects,  in  diminution  of  the 
orifices  of  the  heart,  is  to  augment  it,  and,  consequently,  there  is  no  danger  of 
giving  this  article  in  cases  where  the  energy  of  the  heart  appears  diminished. 

3.  The  frequency  of  the  heart's  action  in  the  case  of  contraction  of  the  orifices, 
preventing  a  return  to  a  normal  functional  condition,  and  keeping  up  the  dis- 
order of  the  circulation,  digitalis  possesses  the  property  of  diminishing  this 
frequency,  and  it  is  not  necessary  to  appeal  to  any  other  mode  of  operation  to 
explain  the  amelioration  of  the  symptoms  under  the  use  of  the  medicine. 

4.  There  is  not  to  be  found  in  the  writings  of  authors  anything  to  prove  that 
digitalis  possesses  diuretic  properties,  and  this  reputation  which  was  given  to  it 
by  Withering,  appears  to  have  been  accepted  without  discussion  by  those  who 
have  followed  him. 

5.  It  is  true  that  in  organic  affections  of  the  heart,  where  the  employment  of 
digitalis  leads  to  reduction  of  the  circulation,  an  abundant  diuresis  is  produced 
But  this  occurrence  is  but  a  mediate  effect  of  the  return  of  the  circulation  to  the 
normal  state. 

6.  All  authorities  are  unanimous  in  attributing  to  digitalis  a  powerful  influ- 
ence over  the  stomach.  In  small  doses  it  stimulates  the  appetite,  but  in  doses 
by  which  it  acts  upon  the  heart,  it  produces  anorexia,  sometimes  nausea,  and 
may  become  the  cause  of  serious  dyspepsia. 

The  following  is  a  summary  of  the  rules  to  be  observed  in  the  administration 
of  digitalis,  according  to  the  observations  of  M.  Pfaff: — 

1.  Digitalis  ought  not  to  be  given  in  increasing  but  in  decreasing  doses. 

2.  It  is  necessary  to  diminish  the  dose,  as  soon  as  the  paralyzing  effect  is 
perceived  upon  the  heart  and  the  arterial  system. 

3.  The  calming  impression  of  the  medicine  upon  pathological  activity  of  the 
heart  is  persistent,  and  continues  sometimes  from  five  to  eight  weeks. 

4.  Digitalis  ought  not  to  be  continued  under  any  form  more  than  six  or  eight 
days.  If  after  eight  days  of  administration,  the  desirable  results  are  not  obtained, 
it  is  best  to  have  recourse  to  squill  or  colchicum.  These  two  last  mentioned 
agents  exercise  a  depressing  influence  upon  the  activity  of  the  heart,  and  if, 
after  their  administration,  digitalis  is  again  used,  its  effects  are  more  speedy 
and  of  long  continuance. 

5.  In  subjects  of  torpid  constitution,  it  is  best  to  precede  the  use  of  digitalis 
by  squill  or  colchicum. 

6.  To  avoid  derangement  of  the  stomach,  it  is  best  to  associate  digitalis  with 
aromatics,  or  bitter  tonics. 

7.  In  the  aged  it  is  best  to  associate  it  with  bark ;  in  tuberculous  subjects 
with  opium;  in  dropsical  cases  with  potassa  salts  or  the  acetate  of  ammonia, 
with  polygala,  squill,  juniper  berries,  &c. ;  in  the  plethoric  with  cremor  tartar, 
magnesia,  sulphate  of  potassa  or  nitre  ;  in  the  anaemic  with  iron. 

8.  In  following  the  employment  of  digitalis  by  arsenic,  it  may  happen  that 
the  cyanosis  attendant  on  the  diseases  of  the  heart  is  lessened. 

In  commenting  upon  the  first  series  of  propositions,  it  is  remarked  by  M. 
Bouchardat  that  in  all  cases  he  prefers  digitaline  for  exhibition  in  accordance 
with  the  views  of  M.  Homolle  and  Quevenne,  and  that  he  concedes  willingly 
two  things :  1st,  that  the  diuretic  property  does  not  appear  clearly  except  in 
certain  pathological  conditions,  and  especially  in  dropsy  connected  with  disease 
of  the  heart;  2dly,  that  this  diuretic  action  is  tardy  and  does  not  occur  until 
after  four  to  six  days,  when  digitaline  has  been  given  in  sufficiently  large  doses, 
yet  he  dares  not  affirm  as  positively  as  M.  Germain  that  the  diuretic  effect  de- 
pends upon  the  return  of  the  circulation  to  the  normal  state.  With  respect  to 
the  second  series,  he  remarks  that  he  is  perfectly  of  accord  with  the  injunction 
that  digitalis  should  not  be  continued  more  than  six  or  eight  days  continuously. 
But  he  disagrees  with  M.  Pfaff  in  prescribing  the  medicine  in  decreasing  doses. 


448 


Bibliographical  Notices. 


[April 


With  regard  to  the  course  of  alternating  with  squill  and  colchicum,  he  perfectly 
agrees  with  the  author. 

As  has  been  the  custom  with  M.  Bouchardat,  the  concluding  portion  of  the 
Annuaire  being  devoted  to  some  subject  of  interest  in  a  hygienic,  therapeutic, 
or  chemico-physiological  point  of  view,  he  has  selected  for  discussion  in  the 
present  issue  a  highly  important  topic,  viz.,  the  "  Abuse  and  the  use  of  Strong 
and  Fermented  Liquors."  The  essay  under  the  above  title,  it  appears,  was  read 
before  the  "  Conference  of  the  Polytechnic  Association  for  Worldng  Men,"  held 
in  the  Amphitheatre  of  the  Faculty  of  Medicine  of  Paris.  We  shall  give  an 
analysis  of  the  facts  and  statements  made  by  the  author. 

Avowing  himself  as  bred  in  the  wine-producing  portion  of  France,  and  ad- 
verting to  the  importance  of  this  industrial  branch  to  the  revenue  and  prosperity 
of  the  nation,  he  commences  his  statement  with  the  following  decided  avowal : 
"  The  more  I  have  carefully  explored  the  depths  of  the  question  as  above  stated, 
the  more  I  have  become  convinced  that  the  undue  use  and  uncontrolled  employ- 
ment of  alcoholic  drink  is  an  enemy  which  the  physician  and  the  philosopher 
ought  most  to  fear  in  its  opposition  to  the  progressive  march  of  humanity." 
The  general  impression  is  that  the  French  nation  is  not  addicted  to  the  vice  of 
drunkenness,  yet  here  is  an  exposition  of  opinion  from  a  practical  observer 
which  is  worthy  of  attention,  and  which  chimes  in  with  the  experience  of  en- 
lightened philanthropists  over  the  world. 

With  respect  to  the  progress  of  hygiene  and  its  results  in  France,  we  are 
informed,  according  to  the  tables  of  Duvillars,  that  before  the  year  1789  the 
mean  duration  of  life  was  28  years.  In  1817  it  had  advanced  to  31  years.  In 
1834  to  34,  and  in  1853  to  36.  It  may  then  be  said  that  the  term  of  life  has 
been  extended  with  the  extension  of  civilization,  yet  may  it  be  said  that  civiliza- 
tion, advancing  in  a  certain  direction,  conducts  to  decadence  and  tends  to  the 
abridgment  of  the  mean  duration  of  life. 

The  crowding  of  people  in  great  manufactories  has  not  favoured  progress  in 
all  particulars,  for  we  may  instance  the  deplorable  state  at  a  certain  period  of 
the  working  population  of  Manchester  and  Lille.  In  some  of  the  quarters  of 
these  cities,  the  mean  of  life's  duration  had  descended  below  the  lowest  number 
that  has  been  stated.  The  movement  of  the  inhabitants  of  the  country  to  large 
cities  is  equally  unfortunate  to  the  average  of  life  and  to  the  progress  of  civili- 
zation. Among  a  population  removed  from  the  country,  there  are  generated 
factitious  wants,  which  are  gratified  at  the  expense  of  real  requirements.  With 
many  other  evils  is  produced  that  state  which  may  be  called  ennui  of  life,  which 
is  combated  by  measures  affecting  the  nervous  system,  and  which  conduce  to 
degeneration,  such  as  indulgence  in  the  use  of  tobacco  and  the  consumption  of 
alcohol. 

In  the  following  order  the  subject  of  alcohol  is  discussed  :  1st,  of  the  alcoholic 
liquors  in  general,  and  their  immediate  action  upon  the  economy ;  2dly,  the  his- 
tory of  the  principal  alcoholic  drinks  and  spirituous  products ;  3d  and  lastly, 
the  exposition  of  the  evils  originating  from  the  abuse  of  alcohol. 

Alcohol  diluted  with  water  is  rapidly  absorbed,  as  has  been  demonstrated  by 
M.  Bouchardat  and  M.  Sandras.  They  gave  to  a  vigorous  dog  a  draught  con- 
taining 150  grammes  of  alcohol  and  50  grammes  of  oil,  which  was  swallowed 
without  difficulty.  In  two  hours  he  was  killed,  when  the  stomach  was  found  to 
contain  but  a  small  quantity  of  the  alcohol,  in  fact  but  one  gramme  of  matter 
containing  it  could  be  obtained  by  distillation.  The  intestines  contained  none, 
and  the  chyme  showed  only  its  presence  by  the  faintest  odour.  It  is  not  taken 
into  the  system  by  the  lacteals,  but  as  determined  by  the  experimenters,  through 
the  veins,  the  blood  of  the  portal  vein  exhibiting  a  notable  quantity  of  it.  It 
has  been  detected  by  Lallemand,  Perrine  and  Dusoy,  in  the  liver,  in  the  brain, 
and  other  organs. 

The  presence  of  alcohol  in  the  blood  and  its  effect  upon  the  blood  itself  can 
be  demonstrated  by  experiment.  It  is  known  that  few  animals  have  a  liking 
for  alcohol,  and  that  some  of  them,  the  rabbit  for  instance,  are  killed  by  small 
quantities,  but  others,  as  cocks,  take  greedily  of  food  impregnated  with  it.  An 
old  cock  was  selected,  who  was  remarkable  for  his  taste  for  bread  soaked  in 


1863.]        Bou  chard  at,  Therapeutics  and  Materia  Medica.  449 


brandy.  He  ate  so  rapidly  that  he  was  soon  in  a  state  of  intoxication,  his  eyes 
shone,  his  gait  was  unsteady,  but  the  important  point  for  consideration  was  the 
change  of  colour  in  his  comb.  To  the  bright  ruby  colour  succeeded  a  black 
hue  ;  the  arterial  blood  was  supplanted  by  venous  blood.  From  this  M.  Bou- 
chardat  argues  that  this  action  upon  the  blood  is  sufficient  explanation  of  the 
sudden  death  from  asphyxia  that  follows  the  ingestion  of  alcohol,  of  which  he 
has  seen  numerous  cases.  It  may  however  be  stated  that  where  death  is  in- 
stantaneous it  is  more  likely  due  to  the  intense  shock  to  the  nervous  system  and 
paralysis  of  the  heart. 

The  question  arises,  is  alcohol  eliminated  from  the  economy,  and  in  what 
manner  ?  This  question,  which  has  been  much  agitated,  M.  Bouchardat  con- 
fesses he  approaches  with  reserve.  M.  Sandras  stated  [Annuaire  for  1847) 
that  a  drunkard,  saturated  with  alcohol,  emits  alcohol  from  the  lungs  by  gas 
and  vapour,  yet  this  is  a  small  portion  of  the  quantity  that  had  been  actu- 
ally absorbed.  It  was  not  found  in  the  perspiration,  and  with  respect  to 
the  urine,  MM.  Lallemand,  Perrin  and  Duroy  were  more  fortunate  than  the 
above  experimenters.  Still  a  quantity  was  obtained  which  in  no  manner  repre- 
sents the  alcohol  absorbed,  so  that  the  conclusions  of  those  gentlemen  are 
not  borne  out  that  alcohol  passes  through  the  economy  without  change.  A 
man  was  closely  observed  for  several  days,  who  with  his  regimen  took  300 
grammes  of  red  wine,  but  no  evidence  was  given  of  free  elimination  in  the  way 
alluded  to.  Hence  the  author  adheres  to  his  opinion  that  a  small  quantity  of 
the  alcohol  taken  is  eliminated,  and  the  balance  is  consumed  and  transformed 
into  carbonic  acid  and  water.  With  reference  to  this  case  of  conversion,  it  has 
been  asserted  that  aldehyde  and  acetic  acid  were  products  within  the  economy, 
but  these  bodies  were  not  detected  either  by  Bouchardat  and  Sandras,  or  the 
three  experimenters  named.  As  a  direct  conflict  exists  between  the  statements 
and  conclusions  of  those  who  have  examined  the  subject,  it  is  open  to  further 
experimental  investigation. 

It  is  argued  that  alcohol  from  its  destruction  in  the  economy  produces  heat, 
and  this  in  a  short  time  after  it  is  taken  in.  Such  physiological  effect  accounts 
for  the  greater  digestion  with  impunity  of  this  combustible  in  winter  than  in  sum- 
mer, and  to  the  largest  extent  by  the  Northern  nations.  Does  it  impart  force? 
The  increase  of  energy  is  but  temporary,  still,  when  the  article  is  properly  used 
it  is  an  assistance  to  labour.  It  is  an  excitant  of  the  nervous  system,  and  if  this 
excitant  is  not  employed  advantageously,  it  is  followed  by  depression.  It  must 
be  admitted,  however,  that  alcoholic  drinks  when  taken  in  moderation  have  an 
incontestable  power  to  excite  the  intelligence,  combat  ennui,  produce  agreeable 
reveries,  without  resulting  in  loss ;  and  it  is  important  that  this  effect  should  be 
secured  when  it  is  first  produced.  This  is  a  law  which  applies  to  all  excitants 
of  the  nervous  system.  Proper  alcoholic  beverages,  therefore,  offer  undoubted 
advantages  to  convalescents  who  have  been  exhausted  by  disease,  and  to  the 
labourer,  who  is  borne  down  by  work,  but  at  the  same  time  it  is  clear  that  an 
excess  is  in  every  case  injurious. 

A  reference  has  been  made  to  the  influence  of  climate  upon  the  action  of 
alcohol  upon  the  system.  From  Mr.  Hus,  a  distinguished  physician,  who  has 
written  a  most  interesting  work  upon  the  abuse  of  alcohol,  we  learn  that  in 
Sweden,  many  workmen  can  from  habit  absorb  a  demi-litre  of  brandy  daily,  and 
that  disease  of  the  brain  is  very  common  with  this  class  of  drinkers,  whose  lives 
are  much  curtailed.  In  Bussia,  the  consumption  of  alcohol  is  enormous,  it  is 
encouraged  by  the  "  farmers  of  the  revenue,"  and  this  is  one  of  the  most  im- 
portant reforms  to  be  accomplished  in  the  fiscal  system  of  the  Emperor. 

If  we  study  the  influence  of  alcoholic  drink  according  to  the  periods  of  life, 
it  will  be  found  that  it  is  most  injurious  in  infancy,  that  the  abuse  of  it  presents 
considerable  danger  for  adolescents,  and  that  in  age  its  indulgence  is  less  pre- 
judicial. At  the  particular  period  of  life,  which  may  be  specified  as  the  "turn 
of  life,"  there  is  danger  from  the  tendency  to  increase  the  quantity  of  alcoholic 
drink ;  the  nervous  system  may  be  undermined,  and  so  far  from  augmenting  the 
amount,  it  ought  rather  to  be  lessened.  It  has  been  said  that  wine  is  the  "milk 
of  old  age,"  but  in  green  old  age  it  should  be  moderately  used.  At  the  period, 
when  from  old  age  there  is  failure  of  power,  when  solid  nourishment  is  with 
No.  XC— April  1863.  29 


550 


Bibliographical  Notices. 


[April 


difficulty  digested,  it  is  stated  by  M.  Bouchardat  that  wine  offers  the  "re- 
source supreme." 

With  respect  to  sex,  it  is  remarked  that  in  consequence  of  the  impressible 
nature  of  the  nervous  system,  alcoholic  drinks  should  be  used  with  great  caution, 
but  further,  a  constant  restraint  is  imposed  upon  the  female  sex,  since  modesty 
and  inebriety  are  entirely  incompatible. 

There  is  a  condition  upon  which  it  is  important  to  insist  in  the  consideration 
of  alcoholic  drinks,  and  that  is  emptiness  of  the  stomach.  It  is  the  custom  to 
take  a  small  drink  of  alcoholic  fluid  upon  rising,  but,  alas,  to  this  the  habit  is 
not  restricted.  The  system  at  this  time  is  in  the  worst  state  for  the  reception 
of  such  ingesta.  The  stomach,  in  consequence  of  its  emptiness,  is  more  liable 
to  irritation  than  after  a  repast  of  solid  aliment,  which  by  stimulating  the  flow 
of  gastric  juice  produces  dilution,  protects  the  mucous  coat  and  induces  slower 
absorption,  or  at  least  in  combination.  Upon  an  empty  stomach  then  alcoholic 
liquors  should  not  be  taken. 

After  discussing  the  conditions  of  drunkenness  and  its  concomitants,  M. 
Bouchardat  enters  upon  the  consideration  of  the  several  kinds  of  alcoholic 
drinks ;  commencing  with  wine.  This  form  of  fermented  liquor  is  regarded  as 
the  most  important,  the  most  useful  when  its  employment  is  properly  regulatedr 
and  the  least  injurious,  in  certain  respects,  even  when  abused. 

After  presenting  the  varieties  of  grapes  constituting  the  stocks  which  furnish 
the  several  kinds  of  wine  in  France,  M.  Bouchardat  gives  a  list  of  the  ingre- 
dients which  are  found  in  the  1000  parts  of  red  wine,  to  wit :  water,  878  ;  alco- 
hol, 100  ;  of  butyric  and  amylic  alcohol,  and  aldehyde,  traces.  Acetic,  capric, 
caphylic,  and  other  ethers,  odorous  matter  and  essential  oils,  constituting  the 
bouquet,  sugar,  mannite,  glycerine,  mucilage,  gum,  colouring  matter  (ceno- 
cyanine),  fatty  matter  and  azoted  matter,  tannin  and  carbonic  acid,  bitartrate 
of  potassa,  tartrates,  racemates,  acetates,  propionates,  butyrates,  lactates, 
citrates,  malates,  sulphates,  nitrates,  phosphates,  silicates,  chlorides,  iodides, 
fluorides,  succinates,  potassa,  soda,  lime,  magnesia,  alumina,  iron,  and  ammonia, 
22.  This  elaborate  composition  of  wine,  however,  is  not  to  be  regarded  as 
uniform.  Some  of  the  principles  are  wanting  in  wine,  and  some  of  them  are  in 
infinite  small  amount.  The  proportion  of  alcohol  varies  in  natural  wines  from 
5  to  15  per  cent.  The  following  table  presents  the  percentage  in  the  wines 
enumerated  : — 


Cote  d'Or,  Nuits  rouge,  1846     ....  13.50 

id,  Mont-Rachel  blanc,  1846    .       .       .  14.00 

Yonne,  Rouge  d'Avallon,  1834      .       .       .  11.14 

—  Blanc  pineau  chablis,  1842  .  .  12.54 
Lot,  Cahors  rouge,  1811    ....  12.00 

—  Cahors  blanc,  1811  ....  12.33 
Gironde,  Bordeaux  rouge,  1841       .       .       .  10.10 

—  Sauterne  blanc   15.00 

Pyrenees  Orient,        Banyuls   15.16 

Drome,  Hermitage   11.0 

Marne,  Sylleri  Mousseux      ....  9.H 

Madeira,  naturel   15.5 

Malaga,  naturel   15.0 

Alicante   15.2 


There  is  no  doubt  that  the  alcohol  plays  an  important  part  in  the  physiological 
and  hygienic  influence  of  wine,  but  this  influence  is  modified  by  many  other 
immediate  principles  to  which  attention  ought  to  be  paid. 

Tannin  and  the  colouring  matter  of  wine  come  from  the  coating  of  the  seeds 
and  the  husk  of  the  grape.  Without  direct  proof,  it  is  probable  that  the  tan- 
nic acid  of  the  grape  is  the  same  as  of  galls.  M.  Glenard  has  isolated  from  red 
wine  two  colouring  substances  which  appear  to  be  immediate,  definite  prin- 
ciples. Acids  exist  always  either  in  a  free  state  or  in  the  condition  of  salts, 
with  very  decided  acid  reaction.  Cremor  tartar  is  found  in  wine  in  the  propor- 
tion of  2-6  in  1,000.  M.  Pasteur  has  discovered  that  succinic  acid  is,  like 
alcohol,  a  constant  product  of  the  breaking  up  of  sugar  under  the  influence 

I 


1863.]        B ouch ard at,  Therapeutics  and  Materia  Medica.  451 

of  alcoholic  ferments.  The  same  is  the  case  with  respect  to  the  glycerine,  the 
proportion  of  which  is  pretty  considerable,  and  which  was  confounded,  before 
those  beautiful  researches,  with  the  so-named  extractive  matters. 

The  bases  are  almost  as  numerous  in  wine  as  acids — they  are  the  same  as 
are  constantly  found  in  the  living  organism.  Potassa  and  soda  should  be  men- 
tioned, which  in  weak  proportion  is  met  with  as  chlorides,  as  in  the  blood  and 
muscles. 

The  bouquet  results  from  the  union  of  several  odorous  matters,  as  alcohol, 
ethers,  aldehyde,  essences,  and  those  analogous  to  what  M.  Millon  terms  per- 
fumes. Well  then  may  be  understood  the  inability  to  approach  by  imitation 
the  flavour  dependent  upon  such  numerous  and  delicate  substances. 

When  we  attempt  to  estimate  the  part  performed  by  wine  in  nutrition,  the 
importance  of  the  association  of  alcohol  with  a  liquid  of  decided  acidity,  not 
only  upon  the  taste,  but  in  the  effects,  is  apparent.  The  simultaneous 
absorption  of  the  acid  abates  the  destructive  action  of  the  alcohol  upon  the 
economy,  and  its  excess  of  action  upon  the  nervous  system.  Tannin  and  the 
colouring  matters  exert  an  action  upon  the  stomach  which,  in  certain  conditions, 
is  favourable.  The  bouquet,  which  impresses  the  taste  and  smell,  is  useful,  as 
it  is  known  that  very  small  amounts  of  sapid  articles  exert  a  happy  influence 
upon  nutrition. 

It  is  asserted  by  M.  Bouchardat,  that  when  wine  is  of  specific  gravity  ap- 
proaching to  that  of  water,  it  is  absorbed  less  rapidly  than  brandy,  and  he 
remarks  that  this  circumstance  is  favourable  to  protracting  absorption,  and  to 
utilizing  the  alcohol,  at  the  same  time  that  the  destructive  effect  is  moderated. 
There  can  be  no  doubt  that  dilution  renders  the  alcohol  less  injurious,  and  the 
greater  the  dilution  the  less  quantity  can  be  introduced ;  but  the  fact  of  a  more 
rapid  introduction  of  brandy  than  of  wine  dependent  upon  its  strength,  is  in 
opposition  to  the  experiments  of  Matteucci  and  Dutrochet,  who  found  that  the 
current,  where  water  and  alcohol  were  concerned,  in  endosmose,  was  from  the 
water  to  the  alcohol,  so  that  it  would  appear  that  until  the  alcohol  is  sufficiently 
diluted  there  is  a  bar  to  its  introduction.  We  incline  to  the  belief  predicated 
upon  these  experiments,  that  the  more  rapid  inebrient  effects  of  a  definite 
quantity  of  alcohol  is  promoted  by  sufficient  dilution  to  promote  absorption. 
It  is  not  necessary  that  wine  or  alcohol  should  be  digested ;  but  dilution  can 
take  place  from  the  fluids  thrown  out  by  the  stomach. 

From  the  complexity  of  inorganic  materials  entering  into  the  composition  of 
wine,  and  which,  to  a  certain  extent,  approximate  those  of  the  human  organism, 
it  can  be  understood  how  serviceable  it  may  be  in  individuals  exhausted  by 
insufficient  alimentation ;  and  with  respect  to  the  effects  of  it  at  different  ages,  the 
same  remarks  are  applicable  as  in  the  case  of  alcohol.  At  any  age  where  there 
is  defect  of  nutrition  it  may  be  profitably  employed.  M.  Bouchardat  admits  the 
advantage  which  the  workman  may  derive  from  the  restricted  use  of  this  bever- 
age, whose  forces  are  much  exhausted  by  his  labour,  but  protests  against  the 
inordinate  use  of  it,  and  especially  on  Sunday.  For  the  sailor  wine  is  preferable 
to  brandy.  As  an  illustration  of  this  fact,  he  cites  two  vessels  employed  in  the 
South  Seas,  the  one  French  and  the  other  English.  In  the  first,  wine  was 
given  as  a  ration,  in  the  other  brandy  (probably  whisky) ;  and  while  the  crew  of 
the  French  vessel  was  exempt  from  scurvy,  that  of  the  latter  was  attacked  by 
it.  The  explanation  is  given  in  the  protective  properties  of  the  wine  containing 
organic  ingredients,  especially  the  salts  of  potassa. 

There  are  certain  morbid  tendencies  which  may  be  favourably  affected  by  the 
moderate  use  of  wine,  as  the  glycosuric  diathesis ;  and  in  marshy  countries  a 
free,  full  diet,  with  an  allowance  of  this  beverage,  constitute  a  powerful  preser- 
vative. In  convalescents  where  nutrition  is  impaired,  with  good  diet  it  is  of 
especial  benefit. 

The  abuse  of  wine  entails  the  same  effects  as  brandy,  although  in  less  degree. 
The  too  free  use  of  it  at  each  repast,  in  which  certain  persons  indulge,  cannot 
be  too  forcibly  reprobated.  To  be  sure  there  are  different  idiosyncrasies  in 
this  respect.  In  some  persons  a  single  glass  produces  redness  of  the  face  and 
headache,  while  with  others  a  pint  produces  no  impression.  With  this  we 
ought  not  to  be  deceived,  the  repeated  excitation  of  the  brain  is  always  pre- 


452  Bibliographical  Notices.  [April 

judicial,  and  it  is  rare  that  this  kind  of  stimulation  of  the  brain  should  be  resorted 
to  to  develop  and  augment  intelligence.  Drunkenness  from  wine  induces  less 
speedy  and  less  profound  disturbance  of  the  apparatus  of  innervation  and  diges- 
tion than  that  from  brandy.  The  inebriates  of  the  wine-producing  countries, 
where  the  article  is  less  strong  in  alcohol,  live  longer  than  those  from  alcohol, 
and  some  of  them  attain  advanced  age.  Dropsy,  connected  with  disease  of  the 
heart,  is  the  affection  of  which  they  die. 

The  following  classification  is  given  of  the  wines  commonly  used  in  France, 
the  red  and  the  white : — 

1.  Wines  in  ivhich  predominates  one  of  the  essential  principles  of  wine. 
(  Dry  wines    .    .    .  Madeira,  Marsala. 

A.  Alcoholic     .  -I  Sweet  wines  .    .    .  Malaga,  Banyuls,  Lunel. 

( De  Paille1    .    .    .  Arbois,  Hermitage. 

B.  Astringent  .  {.^g^U  '•  SSSST 
C  Acid  I  With  bouquet  .    .  Rhine  wine. 

•    •    •  |  Without  bouquet  .  Yin  de  Gouais,  d'Argenteuil. 
D.  Mousseux  Champagne. 

2.  Mixed  or  finished  wines. 

{Burgundy     .    .    .  Clos-Yougeot,  Mont-Rachet. 
Medoc     ....  Chateau-Laroze,  Sauterne. 
Medi  Langlade,  Saint  Georges. 

B.  Without  bouquet.    Ordinary  Burgundy  and  Bordeaux. 

M.  Bouchardat  objects  to  the  division  into  red  and  white  wines.  The  first 
division  of  alcoholized  wines  comprehends  those  of  which  Madeira  and  Marsala 
are  the  type.  As  they  are  delivered  by  commerce,  and  are  almost  always  sur- 
alcoholized,  they  contain  in  fact  25  per  cent,  of  alcohol,  while  fermentation  does 
not  develop  more  than  15  per  cent.  When  administered  in  small  amount  they 
replace  brandy,  and  may  be  useful  to  convalescents,  old  persons,  &c. 

Sweet,  strong  wines  are  also  excellent  pn  the  same  account,  and  they  are 
equally  characterized  by  a  peculiar  flavour.  Some  of  them,  as  Lunel  and 
Banyuls,  are  the  direct  product  of  fermentation  ;  others,  as  Alicante  and  Malaga, 
are  produced  from  the  juice  concentrated  by  heat,  and  are  often  additionally 
alcoholized.  M.  Bouchardat  avows  his  belief  that  by  pursuing  the  same  course, 
wines  of  a  superior  kind  to  those  imported  could  be  procured  in  France,  and 
which  would  be  equal  to  the  best  cordials  for  the  sick  and  those  needing  them. 

The  red  Hermitage  wines  are  properly  classed  among  the  mixed  or  finished, 
but  drunk  in  their  early  stage,  they  have  a  strength  which  is  not  agreeable. 
They  can  be  mixed  with  the  new  wines  of  Gironde  so  as  to  give  to  them  greater 
delicacy,  a  pleasing  aroma,  and  the  property  of  keeping.  This  is  so  well  under- 
stood by  the  skilful  dealers  of  Bordeaux  that  those  wines  have  disappeared  from 
commerce.   The  grapes  furnishing  Rhine  wines  are  recommended  for  cultivation. 

The  preservation  and  improvement  of  wines  is  a  subject  of  importance,  de- 
manding much  information,  nice  observation  and  practice,  which  is  handed 
down  from  person  to  person.  It  is  well  known  in  the  wine  cellars  that  wine 
works  at  different  periods  according  to  the  age  of  the  vine.  This  fact  is  based 
upon  an  attentive  observation  of  phenomena;  it  is  not  a  fanciful  idea.  Vitality 
in  wine  may  lie  dormant  for  several  months,  and  become  manifest  sooner  or 
later  under  an  elevation  of  temperature  or  other  causes  which  cannot  be  now 
entered  upon.  The  first  manifestation  of  this  vitality  is  the  alcoholic  fermenta- 
tion due  to  the  decomposition  of  the  sugars  (glucose,  sugar  of  inulin),  and  the 
formation  of  alcoholic  and  carbonic  acid,  succinic  acid  and  glycerine,  under 
the  influence  of  the  alcoholic  ferment.  The  second  change  is  the  butyro-acetic 
fermentation,  which  consists  in  a  conversion  of  the  tartaric  acid,  in  addition  to 
the  alcohol,  under  the  effects  of  a  special  living  organized  ferment.  The  third 
is  the  acetic  fermentation,  which,  as  M.  Pasteur  has  demonstrated,  is  equally 
established  by  the  action  of  a  living  organized  ferment. 


Wine  prepared  from  dried  grapes  preserved  in  straw. 


1863.] 


Bouchardat,  Therapeutics  and  Materia  Medica. 


453 


At  each  new  decomposition  the  equilibrium  is  deranged  in  so  complex  a  fluid, 
matters  in  solution  are  precipitated,  and  others  which  have  been  precipitated 
are  redissolved.  It  is  by  a  series  of  phenomena  more  complicated  than  has 
been  indicated,  which  may  be  latent  or  violent,  that  vines  attain  perfection,  or 
are  altered  and  undergo  such  change  as  to  indicate  that  they  are  "diseased." 
The  bouquet  appears  with  time.  It  is  necessary  for  it  to  appear,  that  the  wines 
should  be  preserved  for  two,  three,  or  more  years  in  wood,  whence  it  is  removed  to 
bottles,  or  it  may  be  that  months  or  a  year  elapse  before  the  deposit  takes  place 
in  bottles  and  the  bouquet  is  formed.  Acids  of  the  butyric  series  are  developed 
during  the  decomposition  of  the  tartaric  acid  under  the  influence  of  one  or 
several  ferments,  and  ethereal  products  are  generated.  The  production  of  the 
bouquet  always  coincides  with  the  deposit  in  the  bottles  of  a  substance  which 
consists  of  organized  globules,  different  in  the  different  wines.  An  elevated 
temperature  hastens  the  appearance  of  the  bouquet,  but  it  also  favours  the 
development  of  those  diverse  ferments  which  render  the  wine  diseased.  In 
keeping  wines  there  are  two  requisites — the  avoidance  of  an  elevated  tempera- 
ture, and  the  exclusion  of  the  atmosphere. 

Among  the  diseases  of  wine  may  be  mentioned  the  grease,  which  especially 
attacks  the  white  wines.  They  then  become  stringy,  like  the  white  of  egg ;  there 
is  developed  an  organic  substance  which  retains  the  fluid  in  its  meshes,  and 
which  is  at  the  expense  of  the  sugar  remaining  in  the  wine ;  mannite  is  one  of 
the  results.  This  effect  may  be  counteracted  by  tannin,  and  to  prevent  such 
transformation,  or  to  correct  it,  tannin  or  nutgalls  are  used.  M.  Bouchardat 
informs  us  that  he  has  seen  wines  effected  by  grease,  when  placed  in  cool  cellars 
correct  the  disease  by  the  deposition  of  this  matter,  and  recover  spontaneously. 
When  wine  becomes  bitter  the  disease  is  incurable,  but  mixture  may  render  it 
less  disagreeable.  Wines  which  are  termed  "  pricked,"  which  is  the  first  stage  of 
acid  fermentation,  are  used  to  procure  alcohol  by  distillation.  When  the  acetous 
fermentation  has  advanced,  the  wine  is  turned  over  to  the  vinegar  maker. 

M.  Bouchardat  declares  that  the  falsifications  of  wine  are  much  less  nume- 
rous, or  much  more  simple,  than  is  generally  believed.  Most  frequently  the 
practice  is  confined  to  mixing  weak  wines  with  the  stronger,  and  sometimes 
the  least  conscientious  dealer  adds  water.  To  determine  this  latter  fraud,  the 
amount  of  solid  matter  left  by  evaporation  of  a  given  quantity  is  an  index  of 
dilution.  M.  Bouchardat  suggests  a  proceeding  which  he  used  to  detect  the 
adulteration  with  water  in  a  case  which  presented  itself  to  him.  It  is  the  addi- 
tion of  the  solution  of  oxalate  of  ammonia  to  wine  so  as  to  throw  down  a  pre- 
cipitate, or  render  cloudy  the  specimen,  after  it  has  been  decolorized  by  chlorine. 
This  depends  upon  the  detection  of  the  lime-salts  held  by  the  diluted  wine.  In 
old  wine  all  of  these  salts  have  been  deposited ;  but  in  recent  wine,  which  is 
ordinarily  mixed,  they  still  exist  in  the  liquid.  Sometimes  wines  are  plastered ; 
that  is,  the  sulphate  of  lime  is  added — an  old  custom  which  has  been  handed 
down  from  the  Greeks.  The  effect  of  this,  according  to  the  author,  is  to  sub- 
stitute the  bisulphate  of  potassa  for  cremor  tartar,  and  to  overcome  some  of 
the  difficulty  of  preserving  wine  in  warm  locations. 

The  next  alcoholic  beverage  referred  to  by  M.  Bouchardat  is  cider.  This  is 
produced  in  the  north  of  France,  and  especially  in  Normandy.  Its  use  is  traced 
back  as  far  as  the  Boman  occupation  of  Gaul.  In  587,  it  is  known,  that  perry 
was  the  drink  of  the  saintly  Badegonde,  Queen  of  France.  In  the  eighth  cen- 
tury it  was  popular,  and  Charlemagne,  in  attending  to  his  domains,  regarded 
with  extra  favour  those  managers  who  understood  the  making  of  cider. 

Under  the  head  of  the  "Abuse  of  Cider"  it  is  stated  that  the  excess  of  malic 
and  carbonic  acids  has  appeared  to  determine  gastralgia.  It  is  a  drink  which 
is  very  grateful  to  glycosuric  patients ;  but  the  abuse,  and  sometimes  the  use 
even,  is  prejudicial  to  such  diseases.  When  this  drink  produces  inconveniences, 
it  is  attributable  to  bad  preservation.  There  may  be  formed  fungi,  or  mucadi- 
neous  productions,  which  may  be  poisonous,  and  induce  or  predispose  to  dis- 
eases ;  or  there  may  be  a  transformation  of  the  malic  acid  to  butyric. 

Our  author  alludes  to  the  fact  that,  in  his  course  upon  hygiene,  he  has  attri- 
buted that  fatal  disease — miliary  sweat — to  alimentary  drinks,  which  had 
undergone  change  from  mal-preservation. 


454 


Bibliographical  Notices. 


[April 


Under  the  head  of  "Malt  Liquors"  it  is  remarked,  that  an  excess  in  them 
promotes  obesity,  and  in  connection,  the  diminution  of  the  forces  of  life.  Their 
abuse  is  further  placed  among  the  predisposing  causes  of  glycosuria.  In  the 
formation  of  malt  liquors,  M.  Bouchardat  reprobates  the  practice  of  substi- 
tuting any  other  bitter  substance  for  the  hop;  the  articles  employed  being 
gentian,  menyanthes,  lichen  islandicus,  quassia,  picric  acid  or  bitter  of  Wel- 
ter, <fec. 

With  respect  to  the  introduction  of  strychnia,  although  avowing  a  belief  in 
its  use,  no  proof,  except  hearsay,  is  presentee}.  This  subject  has  been  much 
agitated  in  this  country,  and  has  been  placed  at  rest  by  the  investigations  that 
have  been  made.  In  fact  the  use  of  so  deadly  a  poison  is  hardly  possible  without 
accident  or  lamentable  occurrences.  That  cocculus  indicus  is  added  is  beyond 
doubt,  which,  like  hops,  prevents  a  second  fermentation.  "This  dangerous 
sophistication  is  so  prevalent  in  England,"  says  Mr.  Koop,  "that  some  authors 
of  special  treatises  have  given  injunctions  upon  the  subject.  It  is  recommended 
not  to  add  more  than  1500  grammes  of  cocculus  indicus  for  50  bushels  of  malt. 

Under  the  head  of  "Strong  Liquors"  some  interesting  statements  will  be 
found.  Our  limits  forbid,  however,  our  dwelling  too  long  upon  the  information 
which  precedes  the  exposition  of  the  physiological  and  pathological  effects 
which  conclude  these  papers,  and  of  which  we  desire  to  present  an  analysis. 
Before  proceeding  to  this,  there  are  some  points  which  may  be  noticed.  It  may 
be  said  with  truth  that  the  "Eaux  de  vie  de  vin,"  or,  as  they  are  commonly 
called,  "brandies,"  are  the  most  highly  esteemed  of  the  strong  liquors.  Those 
of  France  are  not  excelled  by  any  others  in  the  world.  That  of  Cognac  may, 
for  example,  be  cited  as  most  remarkable  for  the  bouquet.  This  has  induced 
imitation  by  adding  to  rectified  alcohol,  diluted  with  water,  either  ethers  or 
other  odorous  matters,  but  with  little  success,  as  the  fabrication  is  easily  de- 
tected by  the  experienced  palate.  A  fraud  more  difficult  to  detect  consists  in 
distilling  wine  which  produces  this  marked  species  of  brandy  with  inferior 
brandy,  which  thus  to  a  less  degree  is  impregnated  with  the  perfume.  Honest 
distillers  are  justly  indignant  at  this  unfortunate  practice,  which  has  for  its 
infallible  result  the  discredit  of  their  products.  An  association  has  therefore 
been  formed  for  the  security  of  their  business  and  protection  against  imposi- 
tion. It  is  the  stock  of  grapes  called  Folle  Blanche,  furnishing  a  wine  of  mid- 
dling quality,  which  furnishes  this  fine  quality  of  brandy. 

The  brandy  of  Montpellier  is  obtained  by  distilling  the  common  wines  of 
Languedoc  and  of  Provence ;  the  stock  of  grapes  yielding  them  are  designated 
as  Teret  Bouvet  and  Aramon.  It  is  of  good  quality.  That  of  Armagnac  is 
also  esteemed. 

The  liquor  called  Absinthe  is  elaborate  in  composition.  We  are  informed  by 
M.  Bouchardat  that  it  is  made  by  distilling  alcohol  from  a  mixture  with  the 
leaves  of  absinthe,  major  and  minor,  angelica  root,  calamus,  dictamus  of  Crete, 
or  origanum,  star  anise,  &c.  It  is  coloured  with  several  articles,  and  sometimes 
the  salts  of  copper  are  improperly  used  for  this  purpose.  The  superior  quali- 
ties of  the  article  contain  nothing  but  the  alcohol  and  volatile  oils.  It  is  a 
powerfully  stimulating  drink,  but  at  the  same  time  attended  with  pernicious 
effects.  One  of  these  is  to  produce  dryness  of  the  throat,  which  incites  to  new 
libations,  which  ultimately  induce  excessive  indulgence  and  ruin.  M.  Bouchar- 
dat is  of  opinion  that  absinthe  more  predisposes  to  delirium  than  pure  alcohol, 
and  that  the  continuance  of  it  more  frequently  produces  chronic  delirium  and 
progressive  general  paralysis.  His  conclusion  from  observation  is,  that  absinthe 
occupies  the  first  rank  among  dangerous  drinks. 

The  last  portion  of  the  essay  is  occupied  with  the  effects  induced  by  the 
abuse  of  alcoholic  liquors,  or,  in  other  words,  the  divers  disorders  of  the  economy 
which  are  comprehended  by  the  term  chronic  alcoholism.  Under  this  head  are 
placed  the  affections  which  arise  from  the  prolonged  use  of  strong  drink  or 
habitual  intoxication.  The  effects  may  be  arranged  under  the  following 
heads : — 

1.  Digestion. — The  mouth  of  persons  addicted  ordinarily  to  alcohol  is  dry, 
especially  in  the  morning  upon  rising,  the  tongue  is  thick  and  sometimes  cleft. 
Anorexia  is  a  common  effect.    Drunkards  suffer  uneasiness  in  the  epigastrium, 


1863.] 


Bouchard  at,  Therapeutics  and  Materia  Medica. 


455 


have  an  invincible  distaste  for  solid  aliment,  and,  perhaps,  vomiting,  with  the 
discharge  from  the  stomach  of  a  thready  fluid  composed  of  glairy  mucosities. 
It  is  easy  to  understand  how  absorption  from  the  stomach  and  bowels  becomes 
sluggish  in  this  class  of  persons.  Diluted  alcohol  is  easily  absorbed,  but  this  is 
not  the  case  for  normal  aliment.  The  alimentary  fluids  and  nutriment  remain 
in  the  stomach  and  undergo  putrefaction,  whereby  the  breath  becomes  tainted, 
and  digestion  is  permanently  deranged.  The  stomach  at  first  stimulated  by  the 
presence  of  alcohol  pours  forth  an  abundant  secretion  which  is  too  dilute  for 
digestion,  the  mucus  is  augmented,  and  there  is  induced  the  first  departure 
from  healthy  functional  action.  In  time,  however,  when  irritation  has  been 
established  of  a  chronic  character,  or  subacute  inflammation  has  been  produced, 
the  reverse  of  this,  we  think,  is  the  case,  and  there  is  deficiency  of  other  than 
thick  morbid  secretion,  which  interferes  with  absorption  irrespective  of  the 
altered  state  of  the  mucous  membrane.  In  this  condition  morbid  secretions 
are  prone  to  take  place,  even  hemorrhagic  in  character. 

Upon  looking  into  the  state  of  the  alimentary  canal  we  observe  that  drunkards 
are  subject  to  flatulence,  to  colic,  and  that  constipation  is  a  usual  concomitant, 
or  there  may  be  diarrhoea  alternating  with  constipation,  a  usual  result  of  an 
engorged  condition  of  the  liver.  That  disease  of  the  liver  should  be  a  usual  attend- 
ant, can  be  understood  when  it  is  recollected  that  this  organ  is  the  first  to  receive 
and  retain  the  anormal  fluid.  The  disease  of  the  liver  may  be  associated  with 
hypertrophy,  and  fatty  degeneration  with  enlargement.  On  this  material  being 
absorbed  induration  may  be  produced. 

In  northern  countries  cirrhosis  of  the  liver  is  the  common  result  of  the  abuse 
of  alcohol.  In  the  middle  or  temperate  regions,  M.  Bouchardat  states  that 
bilious  fever  and  hepatitis  are  sequences,  and  in  warm  countries  there  is  a  prone- 
ness  to  dysentery.  Considerable  diminution  of  healthy  nutritive  aliment  will 
lead  to  general  wasting  of  the  economy,  and  hence  the  dropsies  which  are  a  fre- 
quent cause  of  death.  The  course  which  nutrition  takes  under  the  use  of  alcohol, 
however,  may  be  stated  to  be,  in  the  first  place,  that  of  exaggeration ;  the  indi- 
viduals addicted  to  drink  become  fuller  in  habit,  with  injection  of  the  skin  and 
redness  of  the  face.  As  the  organs  become  diseased,  with  the  deposit  of  fat  in 
them  their  functional  actions  become  embarrassed,  and  then,  with  depraved 
digestion,  and  the  abstraction  of  proper  elements  of  reparation,  the  fluids  liquefy, 
the  blood  becomes  watery,  and  with  impeded  circulation  existing  in  the  heart  or 
in  the  liver,  effusions  general  or  local  are  inevitable.  The  first  augmentation  of 
size  is  from  the  increase  of  fatty  deposit  in  all  the  tissues  ;  the  second  appear- 
ance of  fulness  is  from  serous  effusion.  This  latter  condition  in  common  language 
is  known  as  the  "  white  bloat." 

2.  Apparatus  of  Innervation. — The  manifestations  of  derangement  of  this 
apparatus  are  as  varied  as  interesting.  They  have  been  well  elaborated  by  the 
labours  of  the  Swedish  physician,  Dr.  Magnus  Hus,  and  are  presented  in  a  thesis 
of  remarkable  merit  by  M.  V.  Racle,  upon  alcoholism.  They  pertain  to  modifi- 
cations of  sensibility,  of  movement,  and  of  intelligence,  so  constantly  observed 
in  habitual  inebriates.  Feebleness  of  muscular  force  is  generally  predominant. 
Generally  this  state  does  not  actually  attain  paralysis.  It  differs  from  the  para- 
lysis that  ensues  upon  apoplexy.  It  advances  gradually  from  the  periphery  to 
the  centres.  It  has  been  described  under  the  names  of  chronic  meningitis  and 
tabes  dorsalis,  and,  in  some  respects,  resembles  the  general  palsy  of  the  insane, 
a  general  progressive  palsy.  After  a  certain  length  of  time  the  extremities, 
especially  the  superior,  commence  to  become  weak;  sleep  is  interrupted  by 
dreams.  At  first  the  ends  of  the  fingers  become  enfeebled,  the  person  can  but 
imperfectly  close  the  hand  and  permits  objects  he  has  grasped  to  escape  from  it. 
This  weakness  extends  to  the  forearm,  to  the  arm,  and  the  shoulder.  It  is 
soon  exhibited  in  the  lower  extremities,  the  gait  becoming  tottering  and  un- 
certain, and  sometimes  it  extends  to  the  muscles  of  the  back,  the  patient  be- 
coming more  and  more  weakened  and  incapable  of  maintaining  any  upright 
position.  The  power  of  voluntary  movement  is  not  actually  wanting,  but  there 
is  an  indisposition  to  move  because  a  strong  effort  is  necessary.  He  cannot 
feed  himself,  and  has  to  be  fed.  This  state  is  little  removed  from  general  para- 
lysis.   There  may  be  conjoined  paralysis  of  the  bladder,  of  the  large  intestine, 


456 


Bibliographical  Notices. 


[April 


of  the  oesophagus,  and  even  of  the  tongue,  and  there  may  be  subsultus  tendinum 
and  cramps.  This  form  is  not  invariable ;  occasionally  accompanying  symptoms 
are  lighter  and  marked  by  anaesthesia,  a  muscular  weakness,  which  comes  on 
slowly,  or  is  brought  on  in  consequence,  of  an  acute  attack  of  disease,  which 
may  be  delirium  tremens,  acute  rheumatism,  erysipelas,  or  an  injury.  If  the 
patient  then  indulges  in  no  excess  it  may  continue  moderate,  but  if  there  be  a 
continuance  of  bad  habits  it  may  assume  the  most  intense  form. 

If  paralysis  of  the  bladder  or  of  the  intestines  has  occurred,  the  expectation 
is  slight  of  any  notable  amelioration  of  the  condition. 

These  symptoms  pertaining  to  the  muscular  apparatus  are  accompanied,  pre- 
ceded, or  followed  by  other  morbid  states  which  contribute  still  further  to 
characterize  this  form.  The  exterior  of  the  patient  is  altered,  his  countenance 
indicates  hebetude  and  slothfulness,  the  white  of  the  eye  has  a  yellow  tinge, 
the  skin  becomes  dry  and  yellow,  emaciation  takes  place,  and  the  muscles 
become  soft  and  flabby. 

With  respect  to  the  intellectual  faculties  a  settled  condition  of  hebetude  over- 
whelms them,  the  memory  is  weakened,  sleep  is  interrupted  and  disturbed  by 
frightful  dreams,  or  hallucinations  of  sight  and  hearing,  or  a  persistent  true 
chronic  delirium  may  exist. 

"Who  drinks,  alas !  but  to  forget,  nor  sees 
That  melancholy,  sloth,  severe  disease, 
Memory  confused,  and  interrupted  thought, 
Death's  harbingers,  are  latent  in  the  draught, 
And,  in  the  flowers  that  wreathe  the  sparkling  bowl, 
Fell  adders  hiss,  and  poisonous  serpents  roll." 

In  connection  with  the  paralytic  condition  that  has  been  described,  there 
exists  a  diminution  of  sensibility  which  is  a  marked  symptom.  It  commences 
with  a  bluntness  of  tactile  perception,  but  extends  to  all  points.  Indeed,  a  per- 
manent anaesthetic  influence  pervades  the  entire  system,  and,  what  is  worthy  of 
note,  the  natural  propensities  are  obliterated.  The  venereal  passion,  as  we  have 
frequently  noticed,  disappears,  as  well  in  females  as  males,  and,  happily,  procrea- 
tion is  thus  prevented. 

In  addition  to  the  features  of  the  picture  that  has  been  drawn  there  are  some 
symptoms  which  although  not  so  frequently  present  should  not  be  omitted.  In- 
stead of  a  diminution  of  sensibility  there  may  be  an  augmentation  of  it,  or  a  spe- 
cies of  hyperaesthesia.  While  one  condition  may  exist  in  a  part  the  other  may  be 
present  in  a  different  portion;  thus  there  may  be  loss  of  sensibility  in  the  toes,  but 
an  exaggeration  of  it  in  the  sole  of  the  foot.  Sensations  of  formication,  glacial 
cold,  alternating  with  burning  heat  in  the  limbs  or  feet  with  localized  neuralgia,  are 
sometimes  present.  Another  manifestation  of  alcoholism  is  found  in  the  tendency 
to  convulsive  attacks.  With  drunkards  the  occurrence  of  fits  is  not  unusual, 
and  this  tendency  may  assume  the  epileptic  form.  Indeed,  epilepsy  and,  as  the 
record  of  insane  asylums  indicate,  mania,  are  the  melancholy  consequence  of 
intemperance.  The  subject  of  the  connection  between  intemperance  and  crime 
is  one  which  has  much  exercised  the  thoughts  of  the  philanthropist ;  it  should 
also  attract  the  attention  of  the  legislator  to  a  greater  extent  than  it  has  hitherto 
done.  The  facilities  of  indulgence  are  scattered  broadcast  throughout  the  land, 
and  from  the  examination  of  our  legislative  enactments,  on  the  inspection  of  the 
social  relations  and  practices  which  are  prevalent,  we  are  led  to  the  conclusion 
that  inducements  to  the  abuse  of  alcohol  are  afforded  liberally  by  the  first,  and 
allurements  of  the  most  captivating  kind  are  presented  by  the  latter.  Viewed 
in  whatever  light  it  may,  as  an  injury  to  the  State  and  to  society  from  the  crimes 
that  may  be  perpetrated,  or  as  a  canker  preying  upon  and  destroying  the  holy 
affections  of  the  family  circle,  it  must  be  regarded  as  a  baneful  evil,  with  which 
morality  and  religion  have  been  unsuccessful  in  the  struggle,  and  against  which 
medical  science  has  in  vain  suggested  remedies.  With  respect  to  the  effects 
upon  civilization  we  may  conclude  this  notice  by  quoting  the  words  of  M.  Bou- 
chardat :  "  That  the  progress  of  humanity  will  not  only  be  checked  by  addiction 
to  the  abuse  of  ardent  spirits,  but  there  is  eminent  danger  of  its  march  becom- 
ing retrograde."  J.  C. 


/ 

1863.]  Lizars,  The  Use  and  Abuse  of  Tobacco.  45? 


Art.  XXVI. — The  Use  and  Abuse  of  Tobacco. — By  John  Lizars,  late  Pro- 
fessor of  Surgery  to  the  Royal  College  of  Surgery,  etc.  etc.  From  the  eighth 
Edinburgh  edition.  12mo.  pp.  138.   Philadelphia:  Lindsay  &  Blakiston,  1859. 

To  determine  with  anything  approaching  to  accuracy  the  influence  upon  the 
human  organism  of  the  habitual  use  of  tobacco,  whether  in  snuffing,  smoking,  or 
chewing,  will  require  a  far  more  extended  and  carefully  conducted  series  of 
observations  than  we  now  possess.  In  the  brochure  before  us,  Mr.  Lizars  has 
presented,  it  is  true,  an  imposing  array  of  testimony,  which,  at  first  sight,  would 
seem  to  prove  very  conclusively  that  the  habitual  use  of  tobacco  is  not  only 
productive  of  some  of  the  most  serious  and  intractable  maladies  to  which  man 
is  liable,  but  that,  even  when  it  does  not  give  rise  to  actual  disease,  it  invariably 
undermines  the  vigour  of  the  constitution  of  those  who  are  addicted  to  it, 
destroys  their  memory,  hearing,  and  vision,  and  is  the  cause  often  of  emascula- 
tion and  cowardice.  When,  however,  we  come  to  examine  the  quality  of  the 
evidence  thus  adduced,  and  subject  it  to  a  careful  analysis,  it  will  be  found  that 
much  of  it  consists  of  mere  opinion,  based  upon  one-sided  and  partial  observa- 
tions, and  of  isolated  facts  which  admit  of  an  easy  explanation  very  different 
from  that  which  Mr.  Lizars  is  inclined  to  give  to  them. 

We  can  scarcely  be  required  to  receive  as  valid  testimony,  in  respect  to  the 
effects  of  the  habitual  use  of  tobacco,  the  statement  of  "  Dr.  Budget,"  in  his 
treatise  on  tobacco,  quoted  by  Mr.  Lizars,  on  the  41st  page  of  his  essay — which 
is,  that  in  America  "it  is  no  uncommon  circumstance  to  hear  of  inquests  on  the 
bodies  of  smokers,  especially  youths ;  the  ordinary  verdict  being  '  died  from 
extreme  tobacco  smoking!1 "  Nor  a  whit  more  valid  is  the  following  libel  upon 
the  American  people,  gravely  quoted  by  Mr.  Lizars,  on  his  62d  page,  as  a  patho- 
logical fact,  from  the  London  Spectator  of  July  5,  1856 :  "  It  is  in  startling 
contrast  with  our  ordinary  train  of  thought  about  the  United  States,  to  hear  it 
even  whispered  as  a  possibility  that  the  race  of  men  which  inhabit  that  country 
is  undergoing  a  process  of  physical  and  moral  degeneration ;  that  the  symptoms 
which  we  have  been  accustomed  to  consider  as  evidences  of  growth,  are  real 
proofs  of  decay;  that  the  people  are,  like  medlars,  rotten  before  they  are  ripe, 
and  that  a  premature  senility  is  the  true  characteristic  of  the  great  Anglo-Celtic 
Republic  of  the  West ;  that  such  a  theory  should  have  been  started  gives  one  a 
shock  which  does  not  pass  off  when  the  facts  upon  which  it  professes  to  rest  are 
calmly  considered.  It  is  said,  for  instance,  that  the  bulk  of  Americans  live 
thoroughly  unwholesome  lives  ;  consume  inordinate  quantities  of  spirituous 
liquor  from  youth  upwards,  and  at  all  hours  of  the  day,  smoke  ^  and  chew 
tobacco  to  excess ;  eating  greedily,  and  giving  themselves  no  time  to  digest  their 
food ;  always  in  a  bustle  and  excitement ;  enjoying  neither  quiet  nor  rational 
recreation,  nor  domestic  peace.  And  how  few  Americans  has  any  Englishman 
known,  of  whom  he  could  say  that  they  were  genial  or  happy !  What  an  anxious, 
nervous,  haggard  expression  of  face,  is  that  by  which  we  instinctively  recognize 
a  Yankee  everywhere!  How  completely  the  manners  and  countenance,  and 
figure  of  the  typical  Yankee  answers  to  the  account  of  the  usual  life  of  the 
people.  What  if  the  bad  habits  of  men  and  women,  acting  with  a  climate  ivhich 
tends  to  exhaust  vitality,  should  really,  in  a  few  generations,  have  produced  a 
palpable  inferiority  of  physique?  The  positive  assertion  of  this  degeneration 
would,  indeed,  be  most  unphilosophic,  on  a  basis  of  facts  such  as  are  patent  to 
common  observation ;  but  that  these  facts  are  patent  is  sufficient  to  excite  the 
alarm  and  sharpen  the  self-watchfulness  of  all  classes  of  Americans,  who  can 
look  forward  to  the  tremendous  consequences  of  a  degradation  of  the  national 
nerve  and  muscle  through  intemperance  and  bad  habits  of  living." 

Such  is  a  specimen  of  one  class  of  facts  upon  which  Mr.  Lizars  bases  his 
verdict  against  the  habitual  use  of  tobacco.  He  would  seem  to  estimate  as  alike 
in  value  all  denunciations  of  the  "foul  weed,"  as  King  James  denominates  it, 
from  whatever  source  they  emanate.  He  has  been  very  industrious  certainly  in 
bringing  together  the  opinions  which  have  been  uttered  against  tobacco,  and 
yet  he  has  overlooked  not  a  few  more  pointed  even  than  those  he  has  collected, 
and  bearing  the  appearance  of  much  greater  exactitude  than  do  many  of  them. 


458 


Bibliographical  Notices. 


[April 


We  would  not  for  a  moment  be  considered  as  advocating  the  use  of  tobac- 
co in  any  form,  or  to  any  extent — in  moderation  or  to  excess.  It  must  be 
manifest  to  every  one  who  has  made  himself  acquainted  with  the  active  toxical 
properties  of  tobacco,  that  it  cannot  be  introduced  into  the  healthy  living 
organism,  even  in  very  minute  quantities,  without  deleterious  consequences 
resulting;  and  that  these  must  necessarily  be  more  decided  and  serious  when 
the  article  is  habitually  indulged  in.  Consequences  which,  though  they  may  be 
reduced  in  speediness  of  occurrence,  and  in  their  intensity,  by  certain  processes 
to  which  the  tobacco  is  subjected  to  fit  it  for  man's  use,  nevertheless  sooner  or 
later  make  their  appearance — effectually  subjugating  their  prey  before  he  is  at 
all  aware  that  his  health  and  strength  are  completely  and  too*  often  irrecover- 
ably gone.  The  exact  nature  and  extent  of  the  deleterious  influences  which 
tobacco  exercises  over  its  votaries  have  never  yet  been  carefully  investigated, 
care  being  taken  to  exclude  all  the  more  prominent  sources  of  error.  There 
has  been  as  much  error  committed  by  those  who  exaggerate  the  baneful  effects 
of  the  habitual  use  of  tobacco  in  chewing,  snuffing,  and  smoking,  as  by  those 
who,  on  the  other  hand,  have  endeavoured,  in  our  day,  to  show  that  tobacco 
habitually  but  moderately  used  is  absolutely  beneficial  to  man,  by  retarding  the 
metamorphosis  of  his  tissues,  and  thus  enabling  him  to  bear  up  for  a  time  under 
the  depressing  effects  of  deficient  diet,  or  the  wear  and  tear  of  violent  and  pro- 
longed muscular  exertion.    Neither  verdict  is  the  true  one. 

To  prove  that  man  may  live  healthful  and  vigorous,  and  bear  up  under  fatigue 
and  privation  without  the  aid  of  tobacco  in  any  form  or  quantity,  there  can  be 
adduced  an  overabundant  mass  of  positive  and  indisputable  testimony;  while, 
on  the  other  hand,  it  must  be  very  evident  that,  in  the  production  of  much  of 
the  evil  that  has  been  attributed  to  the  habitual  use  of  tobacco,  it  constitutes 
only  one  of  several,  perhaps  many,  morbific  causes.  They  who  are  in  the  con- 
stant habit  of  excessive  indulgence  in  the  use  of  tobacco,  by  smoking,  chewing, 
or  snuffing,  most  commonly  belong  to  a  class  of  the  community  by  whom  the 
laws  of  health  are  not  the  most  implicitly  observed,  and  who  incur  disease  by 
exposing  themselves  habitually  to  other  morbific  causes  than  simply  an  indul- 
gence in  the  use  of  tobacco. 

We  are  fully  persuaded  of  the  truth  of  the  following  general  conclusions  to 
which  Mr.  Lizars  has  arrived  in  respect  to  the  effects  of  one  of  the  most  common 
forms  in  which  tobacco  is  used  in  this  country : — 

"1st.  That  excessive  smoking,  long  persisted  in,  is  injurious  to  man  in  the 
highest  degree — physically,  mentally,  and  morally. 

"2d.  That  the  commencement  of  smoking  in  early  life,  and  indulgence  in  the 
practice  early  in  the  day,  cannot  be  too  strongly  condemned,  as  leading  to  most 
pernicious  effects  on  the  constitution. 

"  3d.  That  smoking  even  in  what  is  called  a  moderate  degree  is.  to  say  the 
very  least  of  it,  indirectly  injurious,  more  especially  to  the  young ;  because,  it  is 
not  denied,  it  acts  as  an  inducement  to  drinking — thus  becoming  the  source  of 
intemperance,  and  all  its  accompanying  evils.  It  is  notorious  that  the  practices 
are,  almost  without  exception,  inseparably  associated." 

Although  these  conclusions  relate  only  to  the  practice  of  tobacco  smoking, 
they  will  apply  also  to  the  use  of  the  article  in  chewing  and  snuffing.  Either  of 
the  latter  practices,  commenced  early  in  life  and  largely  indulged  in,  is  produc- 
tive of  most  pernicious  results — Dyspepsia,  nervous  tremors,  etc.,  are  of  common 
occurrence  in  tobacco  chewers,  while  carcinoma  of  the  stomach  has  in  repeated 
instances  been  traced  to  the  use  of  tobacco  in  the  form  of  snuff. 

As  to  the  direct  agency  of  the  habitual  use  of  tobacco  in  the  production  of 
some  of  the  maladies  which  are  attributed  to  it  by  the  authorities  quoted  by  Mr. 
Lizars,  we  are  still  without  the  amount  and  kind  of  evidence  necessary  to  esta- 
blish the  fact  beyond  any  reasonable  doubt.  That  it  often  acts  as  a  co-agent  in 
the  establishment  of  certain  morbid  states  and  conditions  is,  we  think,  a  very 
well  established  fact. 

Upon  a  review  of  all  the  well  attested  observations  that  have  been  adduced 
in  reference  to  "the  use  and  abuse  of  tobacco,"  we  can  very  fully  indorse  the 
advice  which  constitutes  the  motto  of  the  treatise  before  us :  "  Snuffing,  smoking, 
and  chewing  tobacco  are  bad  habits,  and  we  advise  any  gentleman,  who  is  not 
hopelessly  abandoned  to  either,  to  give  it  up."  D.  F.  C. 


1863.] 


459 


QUARTERLY  SUMMARY 

OF  THE 

IMPROVEMENTS  AND  DISCOVERIES 

IN  THE 

MEDICAL  SCIENCES. 


ANATOMY  AND  PHYSIOLOGY. 

1.  Spontaneous  Generation. — Joly  and  Musset  think  that  the  following 
experiment  leaves  but  little  doubt  as  to  the  existence  of  spontaneous  generation. 
They  boiled  in  ordinary  water  the  caecum  of  two  sheep,  along  with  pieces  of 
meat,  during  one  hour.  The  csecums  were  then  filled  with  that  same  water 
when  still  very  hot,  and  a  piece  of  the  boiled  meat  was  introduced  into  each. 
To  secure  a  supply  of  well-filtered  air,  three-quarters  of  the  fluid  was  displaced 
by  purified  hydrogen  gas ;  the  csecums  were  shut  by  means  of  firmly-tied  ligatures 
and  were  put  into  water.  After  several  hours,  diffusion  had  changed  the  con- 
tents of  the  gut.  The  hydrogen  was  replaced  by  filtered  air.  At  the  end  of 
twelve  days,  during  which  the  preparations  were  kept  at  a  temperature  varying 
from  3°  to  25°  C,  the  bags  were  opened,  and  were  found  to  contain  a  number 
of  very  lively  infusoria. 

Schroder,  on  .the  other  hand,  after  numerou$  careful  experiments,  arrives 
at  the  following  conclusions :  1.  All  vegetable  and  animal  forms  derive  their 
origin  from  other  living  vegetable  or  animal  beings.  Omne  vivum  ex  vivo.  2. 
Germs  which  have  been  conveyed  to  a  spot  through  the  medium  of  the  air  are 
always  the  origin  of  the  series  of  specific  products  of  fermentation  and  putre- 
faction which  is  developed  there.  Such  is  most  certainly  the  case  with  germs 
of  mould,  with  the  ferments  of  wine,  milk,  and  urine.  3.  Vegetable  and 
animal  matter  in  which  all  germs  have  been  destroyed  by  boiling,  and  which, 
when  hot,  has  been  shut  off  from  the  direct  influence  of  the  external  air  by 
means  of  cotton-wool,  remains  perfectly  free  from  mould,  fermentation,  or  pu- 
trefaction. The  germs  which  would  be  supplied  by  the  air  are  arrested  in  its 
passage  through  the  cotton-wool.  4.  The  germs  of  most  vegetable  and  animal 
substances  are  destroyed  by  boiling  during  a  short  time  at  a  temperature  of 
100°  C.  5.  But  milk,  yelk,  and  meat  contain  germs  which  are  not  thus  killed. 
Boiling  at  a  higher  temperature,  under  higher  pressure,  or  long-continued 
boiling  at  100°,  will,  however,  always  suffice  to  destroy  these  germs  also.  6.  The 
germs  in  milk,  in  yelk,  and  in  meat,  after  having  been  boiled  at  a  temperature 
of  100°  0.  during  a  short  time,  are  still  capable  of  being  developed  into  the 
specific  ferment  of  putrefaction,  and  sometimes  also  those  in  yelk  and  meat,  at 
least,  into  long  and  indolent  vibriones.  7.  The  specific  ferment  of  putrefaction 
is  of  an  animal  nature.  It  develops  and  multiplies  at  the  expense  of  albuminous 
compounds,  but  does  not  multiply  under  conditions  which  afford  all  the  requisites 
for  vegetable  growth. — Brit,  and  For.  Med.-Chirurg.  Rev.,  Jan.  1863,  from 
Comptes  Rendus,  Jan.  1861,  and  Annal.  der  Chem.  und  Pharm.,  vol.  cxvii.  p.  273. 

2.  Researches  on  the  Physiology  and  Pathology  of  the  Cerebellum. — MM. 
Leven  and  Ollivier  endeavoured  to  gain  accurate  information  on  the  functions 


460 


Progress  op  the  Medical  Sciences.  [April 


of  the  cerebellum  by  puncturing  that  organ  with  a  strong  steel  needle.  The 
experiments  were  performed  on  guinea-pigs,  and  only  such  cases  were  relied 
upon  in  which  no  hemorrhage  took  place  after  the  operation.  If  in  such  cases 
the  injury  was  entirely  confined  to  the  cerebellum,  the  animals  recovered  com- 
pletely in  seven  to  fourteen  days ;  but  if,  in  addition,  the  medulla  oblongata  was 
wounded,  death  was  sure  to  follow  within  twenty-four  to  forty-eight  hours.  In 
simple  lesion  of  the  cerebellum,  the  only  and  invariable  changes  observed  were 
such  as  occurred  in  the  functions  of  the  motory  apparatus.  In  most  instances 
in  which  one  lobe  only  was  punctured,  the  animal  was  drawn  with  an  irresistible 
force  towards  the  injured  side.  It  at  first  revolved  with  great  rapidity  round 
its  axis.  These  movements  then  got  slower  by  degrees,  till  at  last  the  creature 
succeeded  in  finding  rest  by  lying  down  on  the  punctured  side.  This  position 
was  anxiously  retained,  as  if  the  animal  was  all  the  while  conscious  of  the 
impelling  force.  The  writers  explain  the  yielding  to  this  one-sided  impulse 
by  assuming  that  the  muscles  of  the  body,  on  the  side  opposite  to  the  wounded 
lobe,  are  to  some  extent  paralyzed.  Strabismus  was  a  constant  symptom  of  the 
injury. — Brit,  and  For.  Med.-Chirurg.  Rev.,  from  Comptes  Rendus,  vol.  lv.,  1862. 

3.  The  Specifically-Acting  Principles  of  the  Natural  and  Artificial  Pan- 
creatic Juice. — The  researches  of  Alex.  Danilewsky  led  to  the  following  results : 
L  The  natural  and  artificial  juice  of  the  pancreas  shows,  outside  the  organism, 
three  specific  physiological  reactions:  (a)  it  changes  starch  into  sugar;  (b)  it 
dissolves  in  a  characteristic  manner  coagulated  albumen ;  (c)  it  reduces  the 
neutral  fats  into  their  corresponding  acids  and  glycerine.  2.  Each  of  these 
reactions  depends  on  a  specific  substance.  3.  Two  of  these  substances,  the  two, 
namely,  which  effect  the  first  and  second  reaction,  can  be  gained  in  a  more  or 
less  pure  form.  4.  The  existence  of  a  third  substance  which  effects  the  third 
physiological  reaction  of  the  juice  is  highly  probable.  5.  The  specific  substance 
which  corresponds  to  the  first  reaction,  acts  in  a  neutral,  alkaline,  and  acid 
solution,  but  with  different  degrees  of  intensity.  6.  The  digestion  of  fibrin 
in  normal,  natural,  and  artificial  pancreatic  juice,  and  in  a  solution  of  the 
isolated  substance  which  corresponds  to  the  second  reaction,  has  nothing  in 
common  with  a  process  of  putrefaction,  but  is  effected  by  a  physiological  pro- 
perty of  the  juice,  and  more  especially  of  the  isolated  specific  substance.  7. 
This  last-named  substance  extrts  its  power  of  digesting  fibrin  only  in  neutral 
and  alkaline  solutions.  8.  The  amount  of  free  alkali  contained  in  the  solution 
of  the  pure  specific  substance  has  a  great  influence  on  digestion.  9.  A  surplus 
of  free  alkali  and  the  presence  of  free  hydrochloric  acid  do  prevent  the  digestion 
of  fibrin  in  a  solution  of  the  specific  substance.  Danilewsky  states,  further, 
that  the  first  and  second  specific  substances  are  not  pure  albuminates,  but  that 
they  belong  to  the  colloidal  matters. — Brit,  and  For.  Med.-Chirurg.  Rev.,  Jan. 
1863,  from  Virchow's  Archiv,  vol.  xxv.  p.  279. 

4.  Action  of  Electricity  in  the  Metamorphosis  of  Organic  Substances. — 
Herr  Van  Deen  has  for  some  time  carried  on  a  series  of  researches  with  the 
view  of  ascertaining  whether  the  chemical  changes  which  take  place  in  the  animal 
body  can  be  produced  artificially  by  subjecting  the  materials  to  be  changed  to 
the  influence  of  an  electrical  current.  He  has  therefore  submitted  to  a  continu- 
ous current  various  substances  which  form  part  of  the  body  or  are  used  as  food  : 
viz.,  serum  of  blood,  milk,  urine,  albumen  of  eggs,  biliary  and  urinary  acids, 
glycin,  starch,  dextrin,  sugar,  glycerin,  etc.  He  here  relates  especially  the 
result  of  his  experiments  on  uric  acid.  A  little  uric  acid  (which  is  ascertained 
to  be  free  from  urea)  is  mixed  up  in  a  large  quantity  of  water,  so  that  a  part  is 
dissolved.  The  apparatus  employed  consists  of  two  elements  of  Bunsen's  pile, 
with  platinum  electrodes,  which  are  immersed  (being  separated  by  a  piece  of 
glass)  in  the  vessel  containing  the  substance.  In  ten  or  fifteen  minutes,  even 
though  the  current  has  been  weak,  urea  can  be  detected.  If  warm  water  be 
added,  the  action  becomes  more  rapid  and  intense.  The  quantity  of  urea  formed 
is  in  direct  relation  to  the  time  during  which  the  current  has  acted  on  the  uric 
acid.  If  the  current  were  continued  for  a  sufficient  length  of  time,  he  found 
distinct  crystals  of  urea,  the  nature  of  which  he  confirmed  by  forming  nitrate  of 


1863.] 


Anatomy  and  Physiology. 


461 


urea.  He  believes  that  carbonic  and  oxalic  acids  are  formed  with  the  urea,  but 
is  not  positive  on  this  point,  although  he  sometimes  found  crystals  resembling 
those  of  oxalate  of  urea.  (Archiv.fur  die  Holland.  Beitrdge  zur  Natur-und 
Heilk,,  Band  3,  Heft  2,  1862.) 

In  the  same  number  is  contained  a  summary  of  the  results  of  Yan  Deen's 
experiments.  He  has  obtained  by  means  of  the  continuous  current — 1,  from 
albumen ;  cells  resembling  cytoid  corpuscles ;  a  substance  insoluble  in  water 
(fibrin  ?);  urea;  allantoin ;  and  uric  acid  (very  probably):  2,  from  mucus; 
morphological  elements ;  uric  acid ;  and  urea :  3,  from  uric  acid ;  urea  and 
allantoin :  4,  from  glycin  ;  urea :  5,  from  thein,  urea :  6,  from  glycerine  ;  sugar 
and  lactic  acid:  7,  from  inosite  ;  lactic  acid:  8,  from  the  lactate,  formiate,  ace- 
tate, and  butyrate  of  lime ;  carbonate  of  lime  and  water :  9,  from  tartrate  of 
lime  ;  carbonate  and  oxalate  of  lime :  10,  from  gum  ;  carbonate  and  oxalate  of 
lime,  and  water:  11,  from  mannite ;  sugar:  12,  from  amygdalin  ;  sugar;  hy- 
drocyanic acid;  and  probably  volatile  oil  of  almonds:  13,  from  tannic  acid; 
sugar  and  gallic  acid  :  14,  from  salicin  ;  sugar  and  saligenin  or  saliretin.  Elec- 
tricity has  no  influence  on  starch,  dextrin,  glycogen,  or  sugar.  He  has  also 
subjected  various  substances  to  the  action  of  ozone,  with  the  following  results  : 
1,  from  uric  a,cid ;  urea  and  allantoin  :  2,  from  glycin;  urea :  3,  from  glycerine; 
sugar,  and  very  probably  lactic  acid.  Ozone  appears  to  have  influence  on 
starch.  Nitric  acid  and  heat  produce  sugar  from  starch,  the  corpora  amylacea, 
mannite  and  gum.  The  fresh  pancreas  of  a  dog,  whether  the  reaction  was  or 
was  not  acid,  produced  fatty  acids,  glycerine  and  sugar  from  butter ;  and  sugar 
from  glycerine.  At  a  temperature  of  104°  Fahr.  calves'  liver  produced  glyco- 
gen and  sugar  from  glycerine,  sugar  from  starch,  and,  at  the  ordinary  tempera- 
ture sugar  from  dextrin. — Brit.  Med.  Journ.,  Jan.  17,  1863. 

5.  Effects  of  the  Preparations  of  Iron  on  the  Tissue-change. — Dr.  Pak- 
rowsky,  of  St.  Petersburg,  has  directed  particular  attention  to  the  effects  of 
iron  on  the  tissue  change,  in  patients  at  the  hospitals  at  St.  Petersburgh,  who 
were  taking  that  article  for  different  diseases.  He  measured  daily  in  all  the 
patients  the  temperature  of  the  body,  the  amount  of  the  food  consumed,  the 
amount  of  the  excrements,  and  of  the  urine,  with  the  specific  gravity  of  the 
latter,  and  the  amount  of  chlorides  and  urea  it  contained. 

The  following  are  his  conclusions : — 

1.  The  temperature  of  the  body  is  positively  heightened  by  the  use  of  these 
preparations. 

2.  This  increase  results  in  some  cases  very  soon;  in  one  case  it  occurred  after 
five  hours ;  in  others  slower,  and  in  one  case  a  long  interval  and  after  a  large 
dose. 

3.  The  temperature,  the  morbidly  lowered  as  well  as  normal  one,  is  increased; 
and  if  it  ceases  to  rise  after  reaching  a  certain  height,  having  taking  a  certain 
quantity  of  the  iron,  the  temperature  will  rise  more  by  increase  of  the  dose. 

4.  Several  days  after  using  it  the  pulse  rises  also,  although  not  in  all*  cases. 

5.  Yery  soon,  and  consequent  upon  the  increase  of  the  temperature,  the  daily 
amount  of  urea  in  the  urine  increases. 

6.  The  use  of  iron  increases  the  weight  of  the  body. 

7.  Every  preparation  of  iron  produces  the  same  effect,  and  a  change  in  the 
different  preparation  in  the  same  patient  does  not  alter  the  result. 

8.  The  diuretic  effect  of  citrate  of  iron  was  very  distinct  in  two  cases,  but 
was  wanting  in  three  under  the  same  conditions. 

9.  In  all  cases  where  iron  was  used  no  constipation  of  the  bowels  took  place, 
except  a  slight  one  after  iodide  and  lactate  of  iron.  It  was  borne  well,  and  in 
large  doses,  by  the  digestive  apparatus  (nine  grains  pyrophosphate  of  iron,  and 
fifteen  grains  ferrum  hydragenio  reductum). 

10.  Dropsical  transudations  in  the  subcutaneous  cellular  tissue  were  resorbed 
by  the  use  of  iron,  even  in  patients  with  insufficiency  of  the  mitral  valve,  and 
reappeared  after  stopping  with  the  remedy. 

11.  The  increase  of  the  heart's  impulse  and  the  dyspnoea  in  patients  with 
organic  cardiac  diseases  disappeared  even  in  cases  in  which  digitalis  had  done 
nothing. 


462 


Progress  op  the  Medical  Sciences. 


[April 


12.  After  the  normal  temperature  of  the  body  had  been  raised  by  the  use  of 
iron,  it  lasted  a  considerable  time  after  stopping  with  its  use  before  returning 
to  its  normal  condition;  whilst  the  morbid  lowered  temperature  rose  quickly  by 
the  use  of  iron,  it  fell  just  as  quickly  by  stopping  with  its  use — at  least,  where 
the  other  pathological  symptoms  continued,  and  where  consequently  the  cause 
of  the  low  temperature  was  not  cured. 

Referring  to  these  facts,  the  Doctor  lays  down  the  following  maxims :  Taking 
into  consideration  that  the  temperature  of  the  body  and  the  quantity  of  urea  in 
the  urine  is  increased  by  the  use  of  iron,  that  the  oedematous  condition  disap- 
pears and  the  weight  of  the  body  is  augmented,  we  are  fully  justified  in  ascribing 
to  the  iron  a  nutritive  power.  The  increase  of  temperature  indicates  a  stronger 
tissue-change,  for  this  is  constant,  and  accompanied  by  other  symptoms  indicat- 
ing a  heightened  nutrition.  How  this  is  brought  about  it  is  difficult  to  say. 
Increase  of  the  blood  quantum  or  of  the  blood  corpuscules  cannot  be  the  cause  ; 
both  increase  very  slowly,  whilst  the  change  of  tissue  augments  very  quickly. 
Neither  can  the  increase  of  the  pulse  explain  the  elevated  temperature,  as  the 
first  succeeds  the  latter.  The  respiration  is  not  altered  by  the  iron,  hence  can 
not  have  an  influence  upon  the  temperature. 

According  to  Dr.  Pakrowsky,  we  have,  therefore,  to  look  for  the  effect  of  iron 
in  the  finest  arterial  and  capillary  system,  one  of  the  most  important  places  of 
nutrition,  and  the  growth  of  the  tissue  and  organs,  and  so  much  more,  as  the 
disappearance  of  dropsical  transudations  in  the  subcutaneous  cellular  tissue 
after  the  use  of  iron,  points  to  that  system.  The  most  probable  is  the  supposi- 
tion that  the  iron  acts  upon  the  contractile  elements  of  the  finest  arterial 
branches,  which  must  have,  without  doubt,  a  high  and  important  influence  upon 
the  capillary  circulation,  and,  namely,  upon  the  degree  of  the  tonics,  i.  e.,  the 
degree  of  tension  of  the  walls  of  these  ramifications.  The  iron  must  con- 
sequently alter  the  conditions  of  the  diffusion  of  the  elements  composing  the 
tissue  and  organs.  Only  in  this  way  does  it  seem  possible  to  explain  the  quick 
effect  of  iron  upon  nutrition  and  the  resorption  and  the  cedematous  transuda- 
tions.—  Cincinnati  Lancet  and  Observer,  July,  1862,  from  Virchow's  Archiv, 
xxii.,  1861. 

6.  Experiments  on  the  Influence  of  Ozonized  Air  upon  Animals. — Dr.  W.  W. 
Ireland  relates  [Edinburgh  Med.  Journ.,  Feb.  1863)  some  carefully  performed 
experiments  instituted  to  determine  the  influence  of  ozonized  air  upon  animals. 
The  following  are  his  conclusions: — 

1.  Ozonized  air  accelerates  the  respiration,  and,  we  may  infer,  the  circulation. 

2.  Ozonized  air  excites  the  nervous  system. 

3.  Ozonized  air  promotes  the  coagulability  of  the  blood,  probably  by  increas- 
ing its  fibrin.  In  the  blood,  however,  ozone  loses  its  peculiar  properties,  proba- 
bly entering  into  combination  with  some  of  the  constituents  of  the  circulating 
fluid. 

4.  Animals  can  be  subjected  to  the  influence  of  a  considerable  proportion  of 
ozone  in  the  air  for  hours  without  permanent  injury;  but  in  the  end  ozone  pro- 
duces effects  which  may  continue  after  its  withdrawal  and  destroy  life. 


MATERIA  MEDICA  AND  PHARMACY. 

7.  Albuminate  of  Iron  and  Soda  as  a  Therapeutic  Agent. — M.  Angelico 
Fabri  says  that  simple  contact,  at  the  ordinary  temperature  of  the  atmosphere, 
of  white  of  egg  with  a  salt  of  iron  and  soda,  is  capable  of  instantly  producing 
a  soluble  albuminate  of  iron 'and  soda,  or  an  albuminferate  of  the  alkaline  base. 
The  chemical  combination  of  this  compound  is  such  that  it  is  not  altered  by  the 
yellow  ferrocyanide  of  potassium,  the  most  delicate  test  of  the  salts  of  iron, 
unless  a  few  drops  of  acid — as,  for  example,  hydrochloric — be  previously  added 
to  the  soluble  albuminate,  thus  proving  that  this  decomposition  cannot  be 


1863.] 


Materia  Medica  and  Pharmacy. 


463 


affected  by  the  agency  of  the  alkalies,  but  only  by  some  acids,  since  the  potas- 
sium of  the  cyanide  is  not  able  to  displace  the  oxide  of  iron,  becoming  oxidized 
at  its  expense,  and  setting  the  metal  free,  as  occurs  with  the  other  ferruginous 
preparations.  Considering  that  we  find  in  the  blood  albumen,  soda  in  excess, 
and  iron,  and  havkig  shown  how  these  three  bodies,  by  simple  direct  contact, 
form  a  soluble  salt,  the  chemical  combination  of  which  is  so  powerful  that  it  is 
not  destroyed  by  the  most  delicate  reagent,  may  we  not  fairly  infer  that  the  iron 
exists  in  the  blood  as  an  albuminate  of  iron  and  soda  ?  and  would  it  not,  there- 
fore, be  reasonable  to  administer  iron  in  the  various  diseases  in  which  it  is  pre- 
scribed, principally  in  reference  to  the  state  of  the  sanguineous  system,  in  the 
form  of  albuminate,  as  that  in  which  nature  itself  has  placed  it  within  our 
organism — one  of  the  products,  so  to  speak,  on  which  our  life  depends  ?  Physi- 
cians have  been  long  puzzled,  and  are  still  at  a  loss,  how  to  administer  iron,  a 
valuable  remedy,  in  the  manner  most  suitable  to  the  internal  organism  ;  hence 
the  great  number  of  preparations  of  this  metal.  Some  object  to  its  saline  com- 
bination with  mineral  acids,  on  the  ground  that  these  are  inorganic,  and  they 
prefer  giving  it  in  the  metallic  or  oxidized  state,  leaving  the  acids  of  the  stomach 
to  form  with  it  compounds  which  may  be  carried  into  the  circulation.  Others, 
unwilling  to  run  the  risk  of  having  the  greater  part  of  the  iron — little  or  not  at 
all  acted  upon — expelled  with  the  feces,  prescribe  it  in  the  same  state,  but  com- 
bined with  organic  vegetable  acids ;  hence  we  have  the  malate,  tannate,  citrate, 
etc.,  of  iron.  Others,  still  more  scrupulous,  wish  to  have  it  united  to  acids  of 
an  animal  nature,  and  prefer  the  lactate,  the  cyanide,  etc. ;  M.  Fabri  would 
recommend  its  employment  in  the  state  of  albuminate  of  iron  and  soda. — 
Chemical  News. 

8.  Arsenite  of  Cafeine  and  Tanno-Arsenic  Acid  used  as  Antiperiodics. — 
M.  GLastinel,  Professor  at  the  School  of  Medicine  of  Cairo,  has  presented  to 
the  Egyptian  Institute  two  new  arsenical  compounds — viz.,  arseniate  of  cafeine 
and  tanno-arsenic  acid,  both  perfectly  crystallized,  and  having  a  well-defined 
chemical  constitution.  M.  Schnepf,  sanitary  physician  at  Alexandria,  has 
lately  studied  the  therapeutical  action  of  these  two  compounds,  and  the  fol- 
lowing are  some  of  the  cases  which  he  has  recorded.  The  first  case  was  that 
of  a  man,  forty-five  years  old,  who  had  just  had  two  paroxysms  of  fever.  A 
cathartic  and  emetic  were  first  given,  and  produced  vomiting  and  purging; 
then  on  the  next  morning  he  took  twenty  centigrammes  of  tanno-arsenic  acid 
in  some  water,  in  doses  of  one  centigramme  every  quarter  of  an  hour.  This 
was  ou  the  day  when  the  paroxysm  was  expected  to  return,  but  it  was  almost 
entirely  absent,  the  patient  complaining,  however,  of  a  little  frontal  headache. 
The  dose  was  repeated  on  the  two  following  days,  and  there  was  no  return  of 
the  fever,  and  after  a  short  time  the  patient  entirely  recovered.  In  another 
case  the  patient  was  a  man  about  forty  years  old,  attacked  with  a  tertian  fever. 
On  the  day  when  the  fever  was  absent  he  took  twenty  centigrammes  of  tanno- 
arsenic  acid.  The  paroxysm  did  not  return  on  the  following  day,  and  the 
arsenical  compound  was  continued  for  two  days  longer.  The  patient  com- 
plained of  loss  of  appetite  for  a  few  days,  but  soon  recovered  entirely.  The 
third  case  was  that  of  a  man  fifty  years  old,  suffering  from  a  quotidian  fever. 
The  first  attack  surprised  him  suddenly  in  a  violent  manner,  and  was  attended 
with  great  prostration.  The  next  day  an  emetic  was  administered,  but  the 
paroxysm  returned.  After  the  remission,  on  the  third  day,  twenty  centi- 
grammes of  the  tanno-arsenic  acid  were  given,  and  the  paroxysm  did  not  return, 
although  some  headache  remained,  with  wandering  pains  in  the  stomach, 
Twenty  centigrammes  more  were  given,  and  the  fever  never  reappeared,  but 
there  remained  a  prolonged  dislike  for  food,  and  a  painful  sensation  at  the  epi- 
gastrium. Gradually,  however,  the  appetite  returned,  and  the  man  became 
quite  well. — Brit,  and  For.  Med.-Chirurg.  Rev.,  Jan.  18G3,  from  Gazette  des 
Hopitaux,  Jan.  1862. 

9.  Action  of  Digitalis. — Dr.  Fuller,  in  his  recent  work  on  "  Diseases  of  the 
Chest,"  asserts  that  the  general  notion  that  digitalis  exercises  a  depressing 
influence  over  the  action  of  the  heart,  and  therefore  leads  to  accumulation  and 


464  Progress  of  the  Medical  Sciences.  [April 


coagulation  of  the  blood  in  its  cavities,  if  not  actual  paralysis  of  its  muscular 
structure,  is  erroneous.  On  the  contrary,  he  affirms  that  digitalis  stimulates  the 
muscular  fibres  of  the  heart,  and  augments  the  contractility  of  the  capillaries ; 
that  when  it  kills,  it  is  not  by^paralysis,  but  by  tonic  contraction  and  spasm  of 
the  heart ;  that,  such  being  the  case,  it  is  a  valuable  remedy  in  dilatation,  and 
dangerous  only  when  administered  in  hypertrophy.  The  grounds  given  by  Dr. 
Fuller  for  these  opinions  are  those  stated  by  the  author  (p.  592) : — 

"  1st.  During  many  years,  I  have  observed  that  the  cases  of  heart  disease 
most  benefited  by  digitalis  have  been  those  in  which  the  heart  has  been  weak 
and  dilated,  and  the  pulse  feeble  and  irregular.  In  these  the  pulse  has  become 
stronger  and  steadier,  and  less  frequent  under  its  action. 

"  2d.  In  the  only  cases  in  which  I  have  known  death  to  occur  suddenly  during 
the  administration  of  digitalis,  the  heart  has  been  hypertrophied  and  firmly  con- 
tracted. This  may  have  been  a  coincidence,  but,  viewed  in  connection  with  the 
results  of  experiments  to  which  I  shall  presently  refer,  it  is,  at  least,  a  suspicious 
fact. 

"3d.  Dr.  Dickenson  has  pointed  out  (Med.-Chir.  Trans.,  vol.  xxxix.),  and  I 
have  repeatedly  verified  his  observations,  that  digitalis,  if  given  in  full  doses, 
induces  violent  uterine  contraction,  and  checks  uterine  hemorrhage ;  and,  inas- 
much as  its  action  in  staying  menorrhagia  and  uterine  hemorrhage  is  permanent, 
it  seems  fair  to  conclude  that  it  gives  tone  to  the  capillaries,  and  increases  their 
contractility. 

"4th.  This  view  is  borne  out  by  what  I  have  long  since  observed  relative  to 
its  action  in  arresting  haemoptysis,  viz.,  that,  whilst  effecting  the  object  required, 
it  does  not  weaken  but  rather  increases  the  force  of  the  pulse,  though  it  lessens 
its  frequency. 

"5th.  When  patients  die  of  delirium  tremens,  the  pulse  is  usually  rapid  and 
fluttering  before  death,  and  the  heart  is  found  weak,  flaccid,  and  distended11  with 
blood  afterwards.  These  are  just  the  cases  in  which,  on  the  commonly-received 
doctrines  as  to  the  action  of  digitalis,  the  drug  ought  necessarily  to  prove  fatal, 
and  yet  modern  experience  has  shown  that  in  these  cases  it  is  tolerated,  even  in 
excessive  doses.  My  impression  is,  that  its  remedial  action  in  these  cases  de- 
pends on  its  stimulating  the  heart,  subduing  its  irritability,  and  increasing  the 
tonicity  and  contractility  of  the  heart  and  capillaries,  so  that  the  brain  is  better 
supplied  with  blood,  and  the  effusion  of  its  more  fluid  parts,  which  gives  rise  to 
the  •  wet  brains'  of  habitual  drunkards,  is  avoided. 

"  6th.  It  has  been  proved  by  experiments  on  animals  (Dr.  H.  Jones)  that  when 
death  is  induced  by  digitalis,  the  heart  is  not  flaccid  and  distended  with  blood, 
as  is  commonly  supposed,  but,  on  the  contrary,  empty,  contracted  to  the  utmost, 
and  in  a  state  of  tonic  spasm.  All  these  facts  confirm  my  view  as  to  the  action 
of  digitalis ;  and  if  it  is  correct,  its  practical  importance  in  relation  to  the  treat- 
ment of  cardiac  dilatation  can  hardly  be  over-estimated." 

10.  Internal  Exhibition  of  Atropia  and  of  Strychnia.— Br.  Alexander 
Flemming  recommends  (Edinburgh  Med.  Journal,  January,  1863)  solutions  of 
atropia  and  of  strychnia  for  internal  use,  as  being  safer  and  more  efficient  than 
the  Galenical  preparations  of  belladonna  and  nux  vomica. 

The  solutions  of  both  alkaloids  which  he  employs  are  so  proportioned  in 
strength  that  ten  minims  (by  measure)  is  the  ordinary  commencing  dose. 

This  solution  of  atropia  is  made  thus:  "Atropia,  1  grain;  distilled  water,  5 
drachms.  Dissolve  thoroughly  with  the  aid  of  a  few  drops  of  diluted  muriatic 
acid,  and  add  of  rectified  spirit  sufficient  to  make  10  drachms.  This  solution 
keeps  well,  and  is  of  uniform  strength.  The  tincture  and  extract  of  belladonna, 
however  carefully  prepared,  vary  much  in  power.  I  have  found  the  tincture  of 
one  chemist  seven  times  the  strength  of  the  same  preparation  from  another  and 
equally  respectable  chemist;  and  the  extract  is  even  more  uncertain.  The 
internal,  and  at  the  same  time  efficient,  use  of  these  preparations  is  for  this 
reason  very  unsafe. 

"The  solution  is  so  proportioned  that  10  minims,  containing  l-60th  of  a  grain 
of  atropia,  is  the  commencing  dose  for  the  adult.  It  should  be  given  in  a  little 
water,  once  daily,  at  bedtime,  and  on  an  empty  stomach.    The  dose  is  increased 


1863.] 


0 

Materia  Medica  and  Pharmacy. 


465 


daily  by  2  or  4  minims  until  a  slight  degree  of  the  early  physiological  effects — 
dry  throat,  wide  pupil,  and  dim  sight — is  produced.  This  is  attained  with  much 
precision  and  safety;  but  it  may  be  necessary  to  increase  the  dose  to  30,  40,  and 
50  minims,  according  to  the  strength  of  the  patient.  For  children  of  one  year 
and  all  ages  under  one  year,  the  commencing  dose  is  1  minim,  of  two  years,  2 
minims,  of  three  years,  3  minims,  and  so  on  up  to  ten  years,  when  10  minims 
*  may  be  given.  In  verifying  the  commencing  doses  for  children  I  have  been 
assisted  by  my  late  pupil  Mr.  Burnie,  House-Surgeon  of  the  Children's  Hospital 
of  this  place. 

"The  commencing  doses  here  indicated  for  children  and  adults  are  all  fixed 
below  what  may  be  given  with  propriety  in  the  majority  of  cases.  While  weak 
persons  are  readily  influenced  by  atropia,  much  larger  doses  than  those  indicated 
are  necessary  in  strong  subjects,  in  whom,  therefore,  a  few  days  are  usually  lost 
in  the  commencement  of  treatment  before  the  requisite  dose  is  attained.  In  the 
diseases  in  which  I  use  atropia,  as  epilepsy,  asthma,  constipation,  and  hooping- 
cough,  this  delay  has  no  practical  inconvenience.  It  is  perhaps  not  superfluous 
to  note  here,  that  by  minims  I  mean  minims  by  measure.  Ten  minims  of  this 
solution  of  atropia  are  equal  to  eighteen  drops,  in  which  form  it  ought  not  to 
be  prescribed.  I  generally  order  the  solution  alone,  and  direct  the  patient  to 
be  supplied  with  an  Alsop's  minimetre  to  measure  the  dose. 

"I  give  it  once  daily.  The  action  of  one  dose  does  not  subside  completely 
for  sixteen  or  eighteen  hours,  and  if  a  second  be  given  before  the  effects  of  the 
first  have  passed  away,  we  risk  the  production  of  cumulative  action.  When  so 
exhibited  the  degree  of  action  is  less  under  control,  and  we  may  induce  unex- 
pectedly an  alarming  amount  of  atropism.  The  cumulative  exhibition  of  atropia 
is  not  required  to  secure  any  of  its  therapeutical  indications.  It  must  be  given 
on  an  empty  stomach.  The  dose  of  atropia  requires  for  its  due  action  to  be 
promptly  absorbed;  mixed  with  the  contents  of  a  full  stomach  it  enters  the 
system  very  gradually,  and  manifests  its  usual  effects  very  imperfectly,  or  not 
at  all.  This  is  one  reason  why  the  drug,  when  taken  into  the  stomach  of  the 
rabbit,  has  no  action.  It  meets  there  always  a  large  quantity  of  food,  and, 
mixing  with  it,  enters  the  system  very  gradually.  The  kidneys,  meanwhile,  are 
busy  eliminating  it  with  the  urine,  and  the  atropia  is  never  present  in  the  body 
in  sufficient  force  at  any  one  time  to  cause  its  physiological  action.  Several 
experiments  have  satisfied  me  that  this  explanation  applies  to  some  at  least  of 
the  other  examples  of  the  immunity  of  grassfeeding  brutes  to  certain  poisons. 
Their  stomachs  are  always  full.  Lastly,  I  give  the  solution  simply  diluted  with 
a  little  water,  that  it  may  pass  quickly  and  easily  into  the  blood.  Atropia 
should  never  be  given  in  pill,  which  may  undergo  solution  very  slowly  or  not  at 
all,  when  two  or  three  pills  accumulating  in  the  stomach  or  bowels  may,  from 
some  change  in  the  gastro-intestinal  fluids,  be  suddenly  dissolved  and  excite 
'■severe  atropism. 

"  Atropia  is  sometimes  employed  internally  in  the  form  of  valerianate,  but 
this  is  not  a  convenient  preparation.  The  valerianate  is  a  very  deliquescent 
salt,  and  forms  a  gummy  mass,  which  it  is  difficult  to  weigh  with  accuracy. 
Moreover,  it  is  a  delusion  to  suppose  that  the  valerianic  acid  represents  in  any 
sense  the  valuable  medicinal  properties,  of  the  valerian. 

"The  solution  of  strychnia  which  I  use  is  made  thus:  Strychnia,  2  grains; 
distilled  water,  5  drachms.  Dissolve  the  strychnia  thoroughly  with  help  of  a 
little  diluted  muriatic  acid,  and  add  of  rectified  spirit  sufficient  to  make  10 
drachms. 

"  This  solution  has  the  same  advantages  over  the  powder,  extract  and  tincture 
of  nux  vomica,  that  the  solution  of  atropia  has  over  the  tincture  and  extract 
of  belladonna.  It  is  uniform  in  strength,  passes  readily  into  the  circulation, 
and  the  dose  can  be  apportioned  with  accuracy.  The  commencing  dose  is  10 
minims,  and  contains  l-30th  of  a  grain  of  strychnia.  When  employed  for  its 
tetanic  action  the  solution  should  be  taken  in  the  morning,  half  an  hour  before 
breakfast,  and  in  half  an  ounce  of  water,  and  the  dose  increased  2  or  4  minims 
daily  until  a  slight  degree  of  the  physiological  action — stiffness  about  the  jaws 
or  neck,  or  spasmodic  movements  in  the  paralyzed  muscles — of  the  drug  is 
manifested,  when  no  further  increase  should  be  made.  As  a  tetanic  it  should 
No.  XC— April  1863.  30 


466 


Progress  of  the  Medical  Sciences. 


[April 


be  given  only  once  daily,  to  avoid  the  risk  of  cumulative  action  by  giving  a 
second  dose  before  the  operation  of  the  first  has  entirely  subsided.  It  is  taken 
in  the  morning,  so  that  its  action  may  be  over  before  bedtime,  and  the  sleep  is 
not  disturbed.  Lastly,  it  should  be  given  on  an  empty  stomach,  and  diluted 
with  water  to  insure  its  prompt  and  easy  absorption.  Strychnia  ought  never 
to  be  given  in  pill.  It  is  hard  of  solution  in  the  weak  acids  of  the  stomach,  and 
several  pills  may  remain  unchanged  and  accumulated  there  or  in  the  bowels. 
A  change  in  the  secretions  may  then  dissolve  and  transport  them  all  simul- 
taneously into  the  blood,  and  give  rise  unexpectedly  to  alarming  tetanic  symp- 
toms. This  is  commonly  the  correct  explanation  of  the  so-called  cumulative 
action  of  strychnia.  It  is  the  sudden  solution  and  absorption  of  hard  pills  which 
have  accumulated  in  the  stomach  or  bowels. 

"  When  the  strychnia  is  employed  as  a  tonic,  the  dose  of  the  solution  is  5 
minims,  and  it  may  then  be  exhibited  twice  daily  with  safety  and  advantage." 

11.  Recently  introduced  Preparations  of  Iron. — Mr.  Harry  Napier  Draper 
gives  {Dublin  Med.  Press,  Dec.  31, 1862)  the  following  account  of  three  recently 
introduced  preparations  of  iron : — 

L  Ferri  et  Quince  Strychniceque  Citras.  Citrate  of  quinia  and  iron  with 
strychnia. 

Preparation. —  Citrate  of  iron  and  quinia       .     980  grs. 

Crystallized  strychnia  .  .  10  " 
Citric  acid      .      .       .      .      10  " 

Water  10  fluidounces. 

In  nine  ounces  of  the  water  dissolve  the  citrate  of  iron  and  quinia,  and  having 
dissolved  the  strychnia  and  citric  acid  in  the  remaining  ounce  by  boiling,  mix 
the  solutions,  evaporate  to  a  syrupy  consistence,  and  spread  on  plates  to  dry  in 
scales. 

Physical  characters. — Exactly  similar  in  appearance  to  the  citrate  of  iron 
and  quinia.   Its  taste  is,  however,  more  persistently  bitter  than  that  of  this  salt. 

Chemistry. — This  compound  contains  in  each  100  parts,  one  part  of  strychnia, 
twenty  parts  of  quinia,  and  seventy-nine  of  citrate  of  iron.  The  presence  of 
strychnia  may  be  detected  in  the  residue  from  the  evaporation  of  the  chloro- 
formic  solution  of  the  alkaloids  by  the  usual  colour  tests. 

Physiological  action  and  therapeutical  use. — Where  the  use  of  iron  is  not 
contraindicated,  this  salt  and  the  one  next  to  be  described,  furnish  perhaps  the 
safest,  if  not  the  best,  means  of  exhibiting  strychnia.  Five  grains  contain  one- 
twentieth  of  a  grain  of  strychnia. 

Dose — From  two  to  five  grains. 

2.  Ferri  et  Strychnice  Citras.   Citrate  of  iron  and  strychnia. 
Preparation. —  Citrate  of  iron  ....     980  grs. 

Strychnia  10  " 

Citric  acid       .       .       .       .       10  " 
Proceed  as  in  the  case  of  the  preceding  preparation. 

Physical  characters. — Indistinguishable  in  appearance  from  the  simple  citrate 
of  iron.    Taste:  acid,  ferruginous,  and  persistently  bitter;  deliquescent. 

Chemistry. — A  combination  of  citrate  of  iron  with  citrate  of  strychnia ;  100 
parts  contain  one  part  of  strychnia.  The  presence  of  strychnia  may  be  detected 
by  treating  the  dried  and  powdered  salt  with  chloroform,  evaporating  and  apply- 
ing the  usual  tests. 

Physiological  action  and  therapeutical  use. — This  salt  has  been  successfully 
employed  in  dyspepsia  arising  from  atony,  in  chorea,  and  in  suppressed  men- 
struation. 

Dose. — Three  to  six  grains. 

3.  Ferri  et  Zinci  Citras.    Citrate  of  iron  and  zinc. 
Preparation. — Citrate  of  sesquioxide  of  iron    .     4  ounces. 

Carbonate  of  zinc     ...     1  ounce. 

Citric  acid        ....     3  ounces. 

Solution  of  ammonia )  A     «.  .    ,  ... 
■\\rater  \  A  sufficient  quantity. 

Dissolve  the  citric  acid  in  ten  ounces  of  water,  and  add  the  carbonate  of  zinc 


1863.]  Medical  Pathology  and  Therapeutics. 


467 


gradually.  Before  the  point  of  saturation  is  attained  the  solution  will  deposit 
the  citrate  of  zinc  as  an  insoluble  powder.  This  is  to  be  collected  on  a  filter, 
and  having  ascertained  by  drying  a  weighed  portion  of  the  mass  at  212°  how 
much  is  equivalent  to  one  ounce  of  dry  citrate,  this  quantity  is  to  be  heated  in 
a  capsule  with  the  citrate  of  iron  and  ten  ounces  of  water.  When  the  iron  salt 
is  dissolved,  enough  solution  of  ammonia  is  to  be  added  to  effect  solution  of  the 
citrate  of  zinc,  an  excess  of  ammonia  being  avoided.  The  whole  is  now  evapo- 
rated to  a  syrupy  consistence,  and  spread  on  glass  to  dry  in  scales. 

Physical  characters. — Brownish-green  scales.  Taste  ferruginous  and  slightlv 
'•metallic." 

Chemistry. — This  salt  contains  in  addition  to  the  citrates  of  iron  and  zinc, 
ammonia,  and  would  therefore  be  more  properly  named  ammonio-citrate  of  iron 
and  zinc.    Its  composition  as  found  in  commerce  is  very  variable. 

Physiological  action  and  therapeutical  use. — This  salt  is  occasionally  em- 
ployed as  a  tonic  in  cases  where  the  use  of  iron  is  not  contraindicated.  As  an 
elegant  form  of  administering  zinc  it  is  worthy  of  trial  in  diseases  of  the  nervous 
system. 

Dose. — Two  to  five  grains. 

12.  7s  Alcohol  Food? — Dr.  Thomas  Inman  read  before  the  30th  annual 
meeting  of  the  British  Medical  Association  a  paper  on  this  much  disputed 
question. 

The  following  is  a  summary  of  the  facts  which  he  considers  that  he  has 
elicited  : — 

"  1.  Nature  has  provided  in  the  salivary  glands,  the  liver,  and  the  lungs  of 
every  mammal,  an  apparatus  for  converting  all  food,  especially  farinaceous,  into 
alcohol ;  and  we  have  no  evidence  that  such  conversion  does  not  take  place. 

"2.  One  form  of  alcohol  or  another  is  available  for  the  support  of  life — and 
for  restoration  to  health  when  no  ordinary  food  is  or  can  be  digested. 

"  3.  Alcohol,  after  being  taken,  is  incorporated  with  the  blood,  passes  into 
the  various  tissues,  and  ultimately  disappears,  a  small  portion  only  passing 
away  in  the  breath.  We  can  say  no  more  of  bread,  potatoes,  or  oatmeal  por- 
ridge, a  small  portion  of  each  of  which  passes  out  of  the  body  with  the  feces. 

"4.  Alcohol,  in  the  form  of  ale,  porter,  wine,  etc.,  relieves  hunger  and  quenches 
thirst  simultaneously,  and  with  a  completeness  that  is  not  equalled  by  water, 
infusion  of  gentian,  cayenne  pepper,  or  by  turpentine;  i.  e.,  it  does  not  act  as 
water  simply,  or  as  a  stimulant  alone. 

"5.  Wine,  beer,  etc.,  satisfy  the  appetite  when  taken  alone,  and  act  for  some 
time  like  any  solid  food  would  do. 

"6.  When  alcohol  is  mingled  with  other  food,  a  less  amount  of  the  latter  suf- 
fices for  the  wants  of  the  system  than  if  water  had  been  used  as  the  drink. 

"  7.  The  various  forms  in  which  alcohol  is  taken,  have  as  marked  and  specific 
effects  as  have  animal  and  vegetable  articles  of  diet. 

"Individuals  have  subsisted  wholly  upon  one  or  other  of  the  various  forms  of 
alcohol  in  common  use  for  periods  of  great  length  ;  and,  as  it  is  illogical  to  con- 
clude that  they  must  have  lived  on  air,  without  food,  or  on  flies  like  chameleons, 
the  conclusion  is  irresistible. 

"What  that  conclusion  is.  we  fearlessly  leave  every  thinking  man  to  decide." 
—British  Med.  Journ.,  Oct.  4,  1862. 


MEDICAL  PATHOLOGY  AND  THERAPEUTICS,  AND  PRACTICAL 

MEDICINE. 

13.  Diseases  depending  on  Morbific  Fermentation,  and  their  Treatment. — In 
our  number  for  Oct.  last  (pp.  513-15)  we  laid  before  our  readers  an  account  of 
some  researches  by  Prof.  G.  Polli,  regarding  the  therapeutic  powers  of  a  new 
series  of  salts,  the  sulphites.    We  find  in  a  late  number  of  the  Dublin  Quarterly 


468 


Progress  of  the  Medical  Sciences. 


[April 


Journ.  of  Med.  Sci.  (May,  1862)  a  review  of  a  most  interesting  monograph  by  the 
same  Professor  on  zymotic  diseases,  strictly  speaking ;  or  on  such  diseases  as  date 
their  existence  from  the  presence  of  a  fermenting  or  catalytic  principle,  either 
generated  spontaneously  in  the  system,  or  introduced  from  without.  Not  having 
yet  received  this  monograph,  and  believing  that  the  author's  researches  are  of 
great  importance,  we  extract  from  the  above  alluded  to  review  the  following 
notice  of  them  : — 

If  the  author's  experiments  can  be  relied  on,  and  they  seem  to  have  been 
conducted  with  great  sagacity  and  care,  zymotic  diseases  would  be  no  longer 
fatal,  but  would  be  as  amenable  to  treatment  as  many  other  ailments  of  daily 
occurrence,  and  the  remedies  which  cure  those  fatal  diseases,  when  developed, 
would,  in  addition,  seem  to  be  capable  of  acting  as  prophylactics  against  them. 

Dr.  Polli  commences  his  monograph  by  establishing  the  great  importance  of 
fermentation  in  catalytic  actions  ;  he  says : — 

"  By  catalysis,  fatty  principles  which  are  insoluble  are  rendered  soluble  (gly- 
cerine, for  instance) ;  some  bitter  principles,  as  salicine,  are  rendered  sweet 
(glucose) ;  some  inodorous  substances,  myrotic  acid,  for  instance,  are  changed 
into  odorous  essences  (oil  of  mustard) ;  many  neutral  substances,  as  urea  and 
allantoin,  are  changed  into  energetic  alkalies  (ammonia) ;  some  inert  principles, 
or  of  weak  nutrient  capacity,  as  starch,  are  changed  into  inebriating  substances 
(alcohol) ;  and,  finally,  some  principles  of  very  slight  action  on  the  human 
economy,  as  amygdaline,  are  changed  into  energetic  poisons  (oil  of  bitter  almonds 
and  prussic  acid.)" 

Further  on  he  says  : — 

"  Different  putrescible  organic  substances  will,  therefore,  be  capable  of  pro- 
ducing divers  morbific  ferments,  or,  perhaps,  even  the  one  organic  principle, 
during  different  stages  of  its  decomposition,  may  be  capable  of  producing  the 
same  varied  effects  ;  and  if,  in  a  healthy  animal,  some  such  putrescible  substance 
should  be  introduced,  either  by  the  lungs,  the  gastro-enteric  tube,  or  by  the 
cutis,  or  by  injection,  or  by  inoculation,  such  substance  being  in  a  state  of 
decomposition,  different  from  that  which  should  correspond  with  a  normal 
physiological  metamorphosis,  its  introduction  would  give  rise  to  serious  disturb- 
ance in  the  composition  of  one  or  more  of  the  fermentable  components  of  the 
body ;  in  such  cases  the  morbific  ferment  would  be  introduced  from  without. 
But  should  the  natural  metamorphosis  of  the  putrescible  substances  of  our 
organism  deviate  from  its  normal  course,  either  in  consequence  of  atmospheric 
vicissitudes,  great  fatigues,  insufficient  exercise,  mental  anxieties,  or  in  conse- 
quence of  suppressed  secretions  or  excretions,  such  deviations  may  give  rise 
to  compounds  capable  of  effecting  abnormal  modifications  in  the  putrescible 
components  of  our  body,  and  in  this  case  the  morbific  ferment  would  originate 

within  the  living  frame  The  change  which  takes  place  in  the  human 

economy,  in  either  of  these  cases,  is  simply  due  to  a  catalytic  action ;  I  shall, 
therefore,  for  the  sake  of  brevity,  and  also,  at  the  same  time  to  indicate  their 
proximate  causes,  name  all  diseases  arising  in  such  manner  catalytic  diseases. 
Catalytic  diseases  are  truly  diseases  of  blood  poisoning,  for  it  is  in  the  blood 

that  the  morbific  ferments  are  generated,  or  introduced  I  shall 

illustrate  this  operation  by  quoting  some  experiments  of  Schmidt  {Ann.  di  Chim. 
appl.  alia  Med.,  vol.  xxiv.  p.  59).  Blood,  fresh  drawn  from  the  vein  of  a 
healthy  man,  will  not  cause  either  sugar,  urea,  amygdaline,  nor  asparagine  to 
ferment.  If  the  same  blood  be  left  exposed  to  the  air  for  a  few  days,  a  principle 
will  develop  itself  in  it  which  will  be  capable  of  determining  alcoholic  fermenta- 
tion in  saccharine  substances ;  and  after  fourteen  days'  exposure  another  prin- 
ciple, capable  of  causing  both  urea  and  asparagine  to  ferment,  will  be  formed. 
Such  blood,  however,  kept  ever  so  long,  will  not  become  capable  of  inducing 
amygdaline  to  ferment. 

"  Blood  drawn  from  the  veins  of  persons  laboring  under  various  diseases, 
including  cholera,  induces  fermentation  in  a  few  hours,  not  only  in  sugar  and 
urea,  but  also  in  amygdaline.  * 

"  From  these  experiments,  I  conclude  that  the  albuminoids  of  the  blood  can, 
under  certain  conditions,  undergo  such  change  as  to  give  origin  to  specific 
ferments  which  do  not  exist  in  normal  healthy  blood ;  and  that  during  certain 


1863.] 


Medical  Pathology  and  Therapeutics. 


469 


diseases  it  not  only  has  a  greater  tendency  to  produce  these  ferments,  but  will 
even  give  rise  to  others,  both  different  and  more  active  than  such  as  would  arise 
from  the  simple  spontaneous  alteration  of  normal  blood. 

"  Experiments  carefully  practised  on  animals  have  given  the  following  impor- 
tant results : — 

"1st.  That  the  injection  of  a  certain  quantity  of  pus  into  the  circulation 
produces  pyemia,  and  such  diseases  as  are  characterized  by  multiple  abscesses. 

"  2d.  That  the  injection  of  putrid  matter  produces  septicemia,  or  those  dis- 
eases recognized  by  the  name  of  putrid  infections,  and  which  are  characterized 
by  typhoid  gastro-enteritis. 

"  3d.  That  the  injection  of  matter  obtained  from  contagious  diseases,  glanders, 
for  instance,  will  reproduce  the  same  affections. 

"  The  injection  of  from  two  to  four  grammes  of  corrupted  human  pus  into  the 
veins  of  a  dog  of  medium  size,  and  weighing  about  six  or  seven  kilogrammes, 
almost  always  induces  vomiting,  after  a  few  moments,  often  followed  by  alvine 
dejections.  The  dog  looks  stupid  and  weary,  and  stretches  itself  on  its  side,  its 
breathing  gets  hurried,  it  will  neither  eat  nor  drink,  and  thus  it  remains  for  two 
or  three  days.  If  the  lesser  quantity  (viz.,  two  grammes)  of  pus  have  been 
injected,  then  the  dog  about  the  third  day  commences  to  improve ;  it  will  take 
a  little  food,  will  move  itself  a  little,  and  altogether  look  more  lively,  and  by  the 
ninth  or  tenth  day  it  will  be  so  much  better  as  to  be  considered  quite  conva- 
lescent ;  the  wound  also,  through  which  the  injection  was  practised,  and  which, 
at  the  commencement,  had  suppurated  and  spread  itself,  will  now  have  begun  to 
get  small,  and  will  show  symptoms  of  cicatrization.  If,  however,  the  larger 
quantity  (four  grammes)  shall  have  been  injected,  the  dog  will  become  daily 
worse,  presenting  all  the  symptoms  and  running  through  all  the  stages  of  typhoid 
fever;  it  will  keep  constantly  lying  down  in  its  kennel,  in  a  sort  of  stupor;  it 
will  take  no  food ;  it  often  suffers  from  bloody  stools  ;  the  wound  through  which 
the  injection  was  practised  becomes  livid  and  gangrenous,  and  the  dog  dies 
between  the  fifth  and  seventh  day  after  the  operation.  At  the  post-mortem 
examination  the  gastro-enteric  tube  is  found  in  a  general  state  of  inflammation, 
the  mucous  membrane  of  a  dark  red  color,  here  and  there  dotted  with  puriform 
exudation,  at  times  mixed  with  ulcerations,  especially  in  the  neighbourhood  of 
the  pylorus,  and  in  the  caecum ;  the  lungs  are  found  full  of  ecchymotic  spots, 
and  the  blood  contained  in  the  larger  vessels  and  in  the  right  cavities  of  the 
heart,  is  tarry  and  liquid. 

"  The  injection  of  from  one  to  three  grammes  of  putrid  blood  into  the  veins 
of  a  dog,  produces  a  typhoid  disease,  very  similar  to  that  produced  by  the 
injection  of  pus,  but  of  much  more  serious  character.  If  the  lesser  quantity  be 
injected,  the  dog  rarely  vomits,  but  remains  stupid  and  motionless,  standing  on 
its  four  legs,  hangs  its  head  down,  and  will  remain  so,  at  times,  for  hours; 
eventually  it  lies  down,  and  for  several  davs  it  will  neither  eat  nor  drink,  the 
wound,  during  this  time,  becoming  large,  livid,  and  sanious.  By  slow  degrees, 
in  the  course  of  eight  or  ten  days,  the  dog  improves,  but  during  its  entire  illness 
its  complete  prostration  of  strength,  together  with  its  comatose  state,  fully  recall 
to  one's  mind  the  characteristics  of  adynamic  fevers. 

"  If.  however,  the  larger  quantity  of  putrid  blood,. viz.,  three  grammes,  have 
been  injected,  the  dog  both  vomits  and  defecates,  generally  within  a  few  minutes, 
and  the  successive  conditions  of  stupidity,  prostration,  and  coma  are  more 
strongly  marked ;  the  dog  lies  on  his  side,  with  his  legs  stretched  out,  as  also 
his  head  and  neck ;  the  wound  assumes  a  sanious  and  often  a  gangrenous  ap- 
pearance, and  about  the  third,  fourth,  or  fifth  day  after  the  injection,  the  dog 
dies.  At  the  post-mortem  examination  the  entire  gastro-intestinal  tract  exhibits 
the  appearance  of  a  violent  attack  of  gastro-enteritis,  the  mucous  membrane 
of  the  stomach  and  the  intestines  being  deeply  injected,  dark  red,  and  in  some 
spots  ecchymotic  and  bloody,  the  most  inflamed  portions  being  the  stomach,  in 
the  vicinity  of  the  pylorus,  the  duodenum,  and  the  rectum. 

"The  injection  into  the  veins  of  a  dog  of  the  discharge  collected  from  the 
nares  of  a  glandered  horse,  even  where  only  the  small  quantity  of  half  a  gramme 
is  used,  gives  rise  to  the  following  phenomena.  Immediately  after  the  operation 
the  dog  generally  vomits ;  this  is  followed  by  utter  prostration  of  strength. 


470 


Progress  of  the  Medical  Sciences. 


[April 


laboured  respiration,  distaste  for  food,  rapid  wasting  away,  the  formation,  here 
and  there,  under  the  skin  and  between  the  muscles,  of  numerous  unhealthy 
{marciosi,  putrid)  abscesses,  which,  when  laid  open,  exhibit  a  lardaceous  base, 
analogous  to  syphilitic  ulcers  in  the  human  body;  after  death  numerous  clots 
are  found  in  the  lungs  much  more  numerous  and  better  marked  than  in  the  case 
where  pus  was  injected.  These  are  not  merely  ecchymotic  stains,  but  real  clots, 
often  softened  in  the  centre,  and  even  at  times  converted  into  purulent  cavities. 

"  The  summary  conclusion  of  my  experiments,  of  which  I  have  now  only  given 
a  slight  sketch,  is,  therefore4,  that  by  means  of  injections  into  the  blood,  with 
the  above-mentioned  morbific  matters,  very  serious  and  well  marked  forms  of 
disease  can  be  produced,  exhibiting  all  the  general  characters  of  catalytic 
diseases." 

Once  admitted  that  catalytic  diseases  depend  on  the  presence  and  action  of 
specific  ferments  in  the  blood,  the  question  then  arises,  whether  it  would  be 
possible  to  neutralize  them,  and  render  them  inactive,  when  once  introduced  or 
self-developed  in  the  living  body,  Dr.  Polli  answers  in  the  affirmative,  notwith- 
standing the  assertion  of  Claude  Bernard  (whom  he  calls  the  greatest  living 
physiologist),  who,  after  establishing  the  fact  that  fermentation  may  arise  in  the 
blood,  and  give  origin  to  poisonous  principles,  which  may,  in  their  turn,  produce 
certain  grave  accidents  in  the  living  frame,  adds:  "La  neutralization  des  fer- 
ments est  impossible,  parce  que  pour  cela,  il  faudrait  changer  les  proprietes  du 
sang  a  tel  point,  que  la  vie  ne  serait  plus  possible.  (Legons  sur  les  6ffets  des 
substances  toxiques  et  medicamenteuses,  p.  99.)" 

Dr.  Polli  believes  that  we  possess  in  sulphurous  acid,  when  combined  with 
salifiable  bases,  a  means  of  controlling  and  neutralizing  morbid  ferments  in  the 
blood  of  living  animals,  without  in  any  way  vitiating  its  qualities  so  as  to  render 
it  incapable  of  maintaining  life.  After  carefully  studying  the  action  of  sulphu- 
rous acid  on  organic  matters,  and  fermenting  principles  in  particular,  our  author 
came  to  the  conclusion  that  not  only  it  alone,  but  also  its  combinations  with 
earths  and  alkalies,  such  as  the  sulphites  of  soda,  potash,  magnesia,  and  lime, 
possess,  in  a  supreme  degree,  the  power  of  arresting  all  known  organic  fermenta- 
tions and  putrefactive  metamorphoses  of  animal  solids  and  liquids  ;  and  that  its 
action  does  not  depend  on  its  decomposing  the  fermenting  principle,  but  simply 
by  modifying  its  molecular  aggregation,  so  that  it  never  acts  as  a  poison  on  the 
living  organism,  as  do  many  other  substances,  well  known  for  their  antiseptic 
properties,  but  which,  on  account  of  their  poisonous  effects,  cannot  be  employed 
with  safety.    He  says : — 

"  I  made  several  experiments  with  healthy  dogs,  for  the  purpose  of  determining 
the  quantity  of  sulphites  of  soda,  potash,  magnesia,  or  lime  which  could  be 
safely  administered,  and  I  found  that  a  dog  weighing  from  seven  to  eight  kilo- 
grammes, could  not  only  take  with  perfect  safety  from  one  to  fifteen  grammes 
of  such  salts,  but  also  without  the  slightest  inconvenience ;  and  a  dog  of  about 
the  same  weight  took  during  fifteen  successive  days  as  much  as  ten  grammes  of 
these  salts  daily.  Sulphite  of  lime  appears  to  be  even  better  tolerated,  as  on 
one  occasion  I  gave  to  a  dog  of  about  eight  kilogrammes  weight  as  much  as 
fifteen  grammes  of  it  at  a  dose,  and  it  did  not  appear  to  suffer  the  least  incon- 
venience. I  killed  several  healthy  dogs  during  these  experiments,  for  the  purpose 
of  examining  the  state  of  their  stomach  and  intestines,  and  I  constantly  found 
them  in  a  perfectly  normal  condition. 

"  Having  thus  determined  the  harmless  action  of  these  salts,  I  endeavoured 
to  trace  their  course  through  the  living  organism,  and  determine,  if  possible,  by 
what  way  and  in  what  condition  they  are  eliminated  from  the  system,  and  I 
found  that  they  remain  as  sulphites  much  longer  than  might  have  been  supposed 
from  their  aptitude  to  become  sulphates  during  the  oxidizing  process  of  life.  I 
found  sulphites  in  the  urine  for  many  hours  after  their  ingestion,  and  not  sooner 
than  after  a  lapse  of  twenty-four  hours  did  I  find  them  in  the  urine  as  sulphates. 
The  following  experiment  will  prove  interesting :  I  took  three  dogs  in  good 
health,  and  of  about  the  same  weight  and  stature  ;  to  one  I  gave  fifteen  grammes 
of  sulphite  of  soda,  in  the  course  of  twenty-four  hours,  one  gramme  at  a  time, 
wrapped  up  in  a  pellet  of  sausage  meat ;  to  another  I  gave  fifteen  grammes  of 
sulphite  of  magnesia  in  the  same  way ;  and  to  the  last  I  gave  the  same  food,  but 


1863.]         Medical  Pathology  and  Therapeutics. 


no  sulphites.  The  three  dogs  were  put  to  death  at  the  same  time ;  I  collected 
the  blood  and  the  urine  of  each  separately,  together  with  the  liver  and  one 
hind  leg  without  the  skin.  I  easily  detected  the  presence  of  the  sulphites  in 
every  one  of  the  fluids  and  solids  of  the  dogs  to  whom  they  had  been  adminis- 
tered, while  I  failed  in  detecting  even  a  trace  of  sulphurous  acid  in  the  remains 
of  the  third  dog.  All  these  samples,  liquid  and  solid,  were  then  left  exposed  at 
a  temperature  varying  from  12°  to  15°  centigrade,  and  and  after  five  days  the 
urine  of  the  third  dog  exhibited  a  highly  ammoniacal  odour,  and  its  liver  and 
leg  gave  evidence,  by  their  smell,  of  impending  decomposition,  while  those 
parts  which  had  been  taken  from  the  dogs  who  had  received  the  sulphites  still 
remained  perfectly  fresh. 

"These  results  confirmed  my  theoretic  opinions,  and  I  concluded  that  if 
sulphites  taken  by  the  mouth  could  so  modify  the  tissues  of  a  living  animal, 
as  to  give  them  the  power  of  resisting  for  a  longer  period  the  putrefactive 
fermentation  after  death,  so  might  the  presence  of  these  same  sulphites  in  the 
living  tissues  enable  them  to  assist  during  life  the  action  of  those  morbific  fer- 
ments which  constitute  the  essence  of  catalytic  disease." 

In  the  British  Medical  Journal  (Jan.  3, 1863)  it  is  stated  that  M.  Burggraeve 
has  put  into  practice  the  theory  of  Dr.  Polli — the  employment  of  the  sulphites 
in  supposed  cases  of  morbid  ferments  in  the  blood.  M.  Burggraeve  has  com- 
municated to  the  Belgian  Academy  of  Medicine  his  experience  in  the  use  of 
these  agents  in  cases  of  wounds,  abscesses,  and  burns.  The  sulphite  of  mag- 
nesia is  administered  internally — one  gramme  (fifteen  grains),  in  a  glass  of 
sugared  water  four  or  six  times  a  day.  The  sulphite  of  soda  is  employed 
externally,  in  lotions,  etc.  It  produces,  we  are  told,  immediate  local  anaesthe- 
sia, which  is  particularly  appreciated  in  burns,  and  allows  of  their  being 
dressed  and  cauterized  without  pain.  In  sixty-five  cases  of  wounds  thus  treated 
the  effects  produced  were  immediate ;  the  wounds  improved  and  became  of  a 
healthy  colour ;  active  granulation  took  place ;  the  pus  was  scanty,  inodorous, 
and  tough  as  gluten.    The  application  thus  also  acted  as  a  disinfectant. 

Dr.  Lyell,  of  Fifeshire,  in  a  letter  in  this  last-named  journal  (Jan.  31,  1863) 
states  that  he  has  been  induced  by  the  experiments  of  Dr.  Polli  to  try  the  sul- 
phite of  soda  in  diphtheria,  and  the  improvement  after  the  use  of  the  salt  was 
very  marked.  He  dissolved  half  an  ounce  of  the  sulphite  of  soda  in  four  ounces 
of  water,  and  gave  the  solution  in  doses  of  a  tablespoonful  every  four  or  six  hours. 

14.  The  Fermentative  Theory  of  Disease. — In  a  recent  clinical  lecture  on 
Puerperal  Purulent  Infection,  M.  Trousseau,  in  discussing  the  etiology  of 
the  disease,  gives  the  following  resume*  of  M.  Pasteur's  important  observations 
relative  to  the  origin  of  fermentations.  The  discoveries  made  by  this  savant 
concerning  the  organic  corpuscles  contained  in  the  air  furnish  us  with  certain 
theoretical  and  practical  facts  worthy  of  consideration  in  relation  to  the  etiology 
of  purulent  infection. 

M.  Pasteur's  investigations  of  the  doctrines  of  ferments  and  of  spontaneous 
generation  led  him  to  conclusions  totally  different  from  those  previously 
accepted  in  science.  He  noticed  that  all  fermentations  properly  so  called — 
the  lactic,  butyric  fermentations,  for  example — were  always  associated  with  the 
presence  and  with  the  multiplication  of  organized  beings.  According  to  his 
views,  the  albuminoid  matters  do  not  constitute  the  ferments,  but  are  the  ali- 
ments supplying  the  materials  of  growth  to  the  ferments.  The  true  and  actual 
ferments  are  certain  organized  entities.  But,  it  will  be  asked,  from  whence  are 
these  organized  beings  derived  ?    What  is  their  source  ? 

To  learn  this,  M.  Pasteur  first  of  all  proceeded  to  analyze  the  air,  in  order  to 
ascertain  whether  or  not  these  beings  were  present  in  the  air.  For  this  object, 
he  made  use  of  an  apparatus  which  allowed  a  large  quantity  of  air  to  pass 
through  a  peculiar  kind  of  filter.  The  filter,  which  in  fact  was  formed  of  gun- 
cotton,  retained  all  the  particles  floating  in  the  air,  whether  vegetable,  animal, 
or  mineral.  The  gun-cotton,  thus  charged  with  matters,  was  then  dissolved  in 
a  mixture  of  alcohol  and  ether.    The  menstruum  was  then  evaporated ;  so  that, 


Progress  of  the  Medical  Sciences.  [April 


after  its  volatilization,  nothing  was  left  except  the  collected  aeriform  floating 
particles,  which  could  then  be  subjected  to  analysis  chemically  and  microscopi- 
cally. The  dust  thus  obtained  was  found  to  contain  starch,  vegetable  spores, 
and  animals  capable  of  revivification. 

Further  investigation  showed  M.  Pasteur  that  the  spores  present  in  the  acetic 
and  butyric  fermentations  were  of  different  species,  recognizable  by  their  par- 
ticular forms. 

M.  Pasteur  collected  from  different  quarters,  and  under  different  conditions, 
diverse  kinds,  and  preserved  them  in  flasks  of  a  peculiar  construction.  To  pro- 
pagate these  spores,  he  placed  them  in  liquids  proper  for  their  development — 
for  instance,  in  an  infusion  composed  of  distilled  water,  sugar  candy,  tartrate  of 
ammonia  and  ashes ;  and  he  found  that,  in  the  course  of  a  few  days,  they  were 
multiplied  ad  infinitum. 

Now,  for  the  multiplication  of  these  organic  bodies,  it  is  evident  that  the 
requisite  elements  of  nutrition  must  be  supplied  to  them.  The  rudimentary 
plant,  it  appears,  borrows  from  the  infusion  carbon  and  nitrogen,  and  in  ex- 
change it  gives  up  oxygen,  which,  by  union  with  other  elements,  occasions  the 
different  kinds  of  fermentations.  ■  Hence,  then,  we  find  that  the  spore  is  an 
organic  living  cell,  which  is  nourished  by,  and  vegetates  at  the  expense  of,  the 
elements  around  it ;  and  that  certain  determinate  conditions  of  the  medium  in 
which  the  germs  are  ^placed  are  requisite  for  their  vegetation.  When  these  con- 
ditions are  once  determined,  we  may  at  pleasure,  with  the  spores  of  the  alcoholic, 
the  acetic,  or  lactic  ferment,  obtain  the  alcoholic,  acetic,  or  lactic  fermentation. 
There  are  consequently  spores  special  to  each  fermentation. 

The  spore,  again,  may  be  considered  as  an  organic  being,  whieh,  when  placed 
in  a  medium  containing  the  elements  necessary  for  its  life,  its  development,  and 
growth,  secretes  alcohol  and  acetic  or  butyric  acid,  etc. ;  and  in  this  way  fer- 
mentation may  be  regarded  as  an  organic  function,  every  ferment  being  a  germ, 
whose  life  is  manifested  by  the  presence  of  a  special  secretion. 

May  it  not  be  the  same  in  the  case  of  morbid  virus  ?  May  there  not  be  fer- 
ments which,  deposited  in  the  body  at  a  given  moment  and  under  certain  deter- 
mined conditions,  manifest  their  presence  by  the  multiplication  of  their  products  ? 
Thus  the  variolous  ferment  may  produce  the  variolous  fermentation  and  its 
thousand  pustules.  Other  virus  may  act  locally,  but  at  last  modify  the  whole 
body.  Thus,  for  instance,  hospital  gangrene,  malignant  pustules,  and  con- 
tagious erysipelas.  And  may  it  not  be  said  that,  in  such  cases,  the  organic  fer- 
ment or  matter  may  be  conveyed  by  the  lancet,  by  the  air,  or  by  the  dressings? 

Moreover,  M.  Chalvet,  in  his  interesting  researches  into  the  causes  of  hospital 
insalubrity,  has  shown  that  the  analysis  of  the  air  in  the  wards  of  St.  Louis  fur- 
nished him  with  a  large  quantity  of  starch-corpuscles  ;  and  that  a  large  quantity 
of  putrescible  organic  matter  was  collected  in  the  bed-curtains,  and  on  the  walls, 
windows,  etc.  He  also  showed  that  the  linen,  as  returned  from  the  laundry, 
was  still  tainted  with  organic  detritus,  linseed,  and  spots  of  various  kinds.  May 
not  linen  thus  stained  with  altered  pus  and  blood  be  the  vehicle  of  the  conta- 
gion? We  know  that  vaccine  matter  maybe  preserved  on  cotton  or  linen 
threads. 

M.  Chalvet  has  also  shown  that  the  vapour  of  water  condensed  in  the  neigh- 
bourhood of  a  suppurating  focus  is  strongly  charged  with  irregular  corpuscles, 
resembling  dried  pus.  Eiselt,  of  Prague,  also  asserts  that  he  has  seen  small 
cells  like  those  of  pus  spread  through  the  air  of  a  ward  in  which  an  epidemic  of 
purulent  ophthalmia  was  raging.    On  this  point  M.  Chalvet  says : — 

"  The  atmosphere  of  a  hospital  is  no  longer  a  vague  expression.  The  air  of 
it  differs  essentially  from  pure  air.  In  1860  I  witnessed  the  experiments  of  M. 
Reveil,  and  recognized  in  the  most  positive  manner  the  presence  of  organic  cor- 
puscles in  the  apparatus  constructed  by  that  skilful  chemist.  We  then  ob- 
served chiefly  cells  and  the  cUbria  of  epithelial  cells ;  corpuscles  of  divers  forms, 
which  became  yellow  under  the  action  of  nitric  acid;  and  bits  of  charpie  charged 
with  these  corpuscles.  Under  like  conditions  he  saw,  with  M.  Kallmann,  in 
the  laboratory  of  M.  lleveil,  organic  debris  incrusted  with  agranular  substance, 
which  gave  the  reaction  of  copper.  The  dust  thus  observed  was  collected  in  an 
ophthalmic  hospital,  where  sulphate  of  copper  was  largely  used  as  a  caustic. 


1863.]  Medical  Pathology  and  Therapeutics. 


"  Dust,  collected  by  dusting  the  walls  of  the  ward  St.  Augustine  at  St.  Louis, 
furnished  me  with  36  per  cent,  of  organic  matter.  At  another  period,  in  the 
laboratory  of  M.  Reveil,  dust  collected  from  the  same  quarter  yielded  46  per 
cent,  of  organic  matters,  which  consisted  in  large  part  of  epithelial  cells,  and 
yielded  a  horny  smell  when  calcined. 

"  When  wetted,  the  dusty  powder  quickly  gives  off  a  very  fetid  smell. 
Doubtless,  the  thick  layer  of  dust  covering  the  walls  of  our  old  hospitals  may 
produce  gases  capable  of  favouring  the  transport  through  the  air  of  corpuscles, 
which  perhaps  play  a  very  important  part  in  the  air  of  hospitals." 

May  not,  asks  M.  Trousseau,  considerations  of  this  kind  furnish  us  with  use- 
ful information  regarding  the  etiology  of  diseases  ?  There  may,  perchance, 
exist  in  the  air  at  a  given  moment  morbid  germs,  which  will  some  day  enable 
us  to  seize  upon  the  cause  of  endemic  and  epidemic  diseases. 

"  These  germs  will  not  be  developed  as  readily  in  all  patients,  because  the 
conditions  of  their  reception  vary  infinitely.  Some  patients,  like  certain  earths, 
will  not  receive  certain  germs.  The  wind  may  spread  the  same  seed  widely 
over  a  country,  and  yet  the  grain  will  not  spring  up  everywhere  alike.  Here 
the  soil  may  be  too  wet ;  there  too  dry ;  here  other  germs  have  grown  up,  and 
stifled  the  new  seed.  Just  so  is  it  with  morbid  germs  and  ferments.  They,  in- 
dividually, require  conditions  favourable  to  their  development." 

Eeasoning  upon  the  facts  supplied  by  MM.  Pasteur  and  Chalvet,  M.  Trous- 
seau argues,  speaking  of  purulent  absorption,  that  the  existence  of  a  wound, 
whatever  its  seat  or  its  size,  is  a  necessary  condition  of  the  affection ;  and  the 
specific  character  of  the  pus,  he  believes  (as  does  M.  Robin),  lies  in  its  serum. 
And  then,  applying  M.  Pasteur's  theory  of  vegetable  spores  in  this  domain  of 
pathology,  he  asks  :  May  not  the  analysis  of  the  air  of  hospitals  and  of  great 
cities  one  day  show  us  the  presence  in  it  of  morbific  germs,  analogous  to  vege- 
table sporules,  which  will  grow  and  multiply  whenever  they  meet  with  the 
conditions  necessary  or  favourable  to  their  growth  and  development — when,  for 
example,  they  come  into  contact  with  wounds  ? 

M.  Pasteur's  researches  have  upset  the  theory  of  spontaneous  generation, 
and  have  shaken  to  its  foundation  the  theory  of  multiplication  by  fermentations  ; 
and  the  recent  experiments  and  observations  of  MM.  Eiselt,  Reveil,  and  Chalvet 
afford  great  support  to  the  hypothesis  above  given  of  the  origin  of  purulent 
absorption.  The  observations  of  these  gentlemen  show  that  in  the  hospitals  of 
Berlin  and  Paris,  the  air  around  the  beds  of  patients  contains  globules  of  pus, 
and  filaments  of  charpie  infested  with  putrid  matters.  Why  may  not  epidemics, 
then,  have  their  etiological  source  in  morbid  entities  floating  in  the  atmosphere  ? 
These  different  matters  may  act  in  different  ways.  Some  of  them  may  enter 
the  respiratory  mucous  membrane,  as  perhaps  do  those  of  smallpox,  cholera, 
and  glanders.  Others  again — the  purulent  sporule,  for  example — may  require 
a  special  entrance  into  the  body — a  wound.  In  such  case  the  morbid  force,  the 
purulent  or  putrid  sporule  in  contact  with  the  wound  may  act  like  the  vegetable 
sporule,  which  in  contact  with  a  special  medium,  produces  carbonic  acid,  appro- 
priating to  itself  oxygen,  and  thus  multiplying  very  rapidly  and  ad  infinitum. 
The  morbid  sporule,  finding  in  the  wound  the  necessary  conditions  for  its  life 
and  growth,  may  engender  new  sporules,  or  so  modify  the  serosity  of  the  mucous 
or  cutaneous  wound,  that  the  serosity,  once  absorbed,  will  carry  with  it  into  all 
parts  of  the  body  the  purulent  essence,  and  so  give  rise  to  the  manifestation  of 
purulent  infection. 

If  this  be  true,  therapeutics  will,  we  may  fairly  hope,  be  as  powerful  as  the 
disease  ;  for,  as  the  vegetable  sporules  will  die  if  deprived  of  the  medium  neces- 
sary for  their  growth,  so  likewise  may  these  morbific  sporules  be  destroyed  if 
attacked  at  the  moment  when  they  are  deposited  on  the  wound,  or  if  the  wound 
be  so  modified  as  to  be  rendered  unfitted  for  their  growth.  Thus  may  not 
cauterization  be  destructive  of  these  sporules  ?  Is  not  diphtheritis  often  modified 
or  removed  by  special  agents,  such  as  tannic  acid,  or  even  glycerine  ?  Are  not 
the  most  subtle  poisons  destroyed  by  early  cauterizings  of  the  inoculated  wound 
— the  virus  of  syphilis,  of  serpents,  and  of  hydrophobia,  for  example?  The 
therapeutic  agent  in  such  case,  applied  in  time,  destroys  the  virus  of  the  poisons, 
or  it  converts  the  wound  into  a  non-absorbing  surface. 


474  Progress  of  the  Medical  Sciences.  [April 


We  can,  it  is  true,  never  hope  to  purge  the  atmosphere  of  the  many  morbid 
agents  floating  in  it;  but  public  hygiene  may  diminish  their  intensity.  And  if 
we  cannot,  in  dressing  wounds,  remove  all  sources  of  impurity,  we  can,  at  all 
events,  render  the  wound  unfitted  for  the  reception  or  absorption  of  the  morbid 
matters. 

M.  Trousseau  quotes  M.  Maisonneuve  to  show  that  the  actual  cautery  is  the 
best  means  for  the  prevention  of  purulent  absorption ;  and  he  suggests  that  the. 
ligature  of  arteries  may,  in  this  respect,  be  considered  a  retrograde  step.  The 
ligature  keeps  up  suppuration,  and  is,  therefore,  a  direct  cause  of  purulent 
infection.  On  this  score,  however,  neither  M.  Trousseau  nor  M.  Maisonneuve 
will  find  many  adherents  in  opinion. 

Erysipelas,  M.  Trousseau  adds,  in  surgical  wards  is  always  most  frequent  in 
times  when  puerperal  fever  is  raging  epidemically.  "We  cannot  divide  erysipelas 
into  spontaneous  and  traumatic ;  for  it  is  invariably  traumatic.  It  always 
commences  with  a  wound.  Carefully  examine  your  patients,  and  you  will  find 
that  all  those  who  present  themselves  with  so-called  spontaneous  erysipelas  had 
previously  had  some  wound  in  the  pharynx,  the  amygdalae,  the  mouth,  some 
scratch  about  the  lips,  eczema  about  the  ears,  or  some  cutaneous  disease  of  the 
scalp. 

There  is,  in  all  cases  of  erysipelas,  a  wound  ;  and  with  the  wound,  in  fact,  the 
erysipelas  commences.  When  erysipelas  appears,  it  is  generally  as  an  epidemic. 
Moreover,  there  appears  to  be  a  distinct  relation  between  erysipelas  and  purulent 
infection.  The  gravity  of  these  diseases  generally  increases  or  diminishes  at  the 
same  time.  They  occur  at  the  same  time,  in  the  same  ward,  in  the  same  hospital 
or  town.  Moreover,  erysipelas  of  a  serious  kind  often  ends  in  purulent  absorp- 
tion ;  and  thus  we  find  relations  existing  between  phlebitis,  purulent  infection, 
and  erysipelas.  They  may,  in  fact,  be  only  different  degrees  of  inflammation  of 
venous  tissue,  having  one  common  cause  of  origin,  a  wound,  and  associated  with 
one  particular  epidemic  ;  and  they  may  be  modified  in  their  pathological  evolu- 
tions by  topical  applications  to  the  wound,  or  the  germ  deposited  on  the  wound. 

Thus,  then,  we  find,  in  conclusion,  that  there  is  no  such  thing  as  purulent 
infection  without  a  wound ;  that  a  wound  is  the  necessary  and  obligatory  con- 
dition of  its  existence;  that  every  wound  may  be  attended  with  suppurative 
-phlebitis.  Suppurative  phlebitis,  the  most  ordinary  source  of  infection,  causes 
the  pus  to  be  passed  as  such  into  the  circulation.  The  pus  may  be  introduced 
in  a  continuous  or  in  an  intermittent  manner.  Purulent  infection  may  also  result 
from  abscesses  of  the  coats  of  the  aorta  and  of  the  heart ;  but  this  cause  of 
infection  is  rare. 

Capillary  phlebitis  may  cause  the  infection  through  the  production  of  pus ; 
but  in  the  epidemics  of  purulent  infection,  the  serosity  of  wounds,  modified  in  a 
special  manner  by  atmospheric  conditions,  may  be  absorbed  by  the  capillaries, 
without  any  erosions  of  the  vessels. 

Such  are  the  views  on  the  subject  lately  delivered  by  M.  Trousseau.  We  need 
hardly  tell  our  readers  that,  however  rational  they  are,  they  are,  as  yet,  only 
hypotheses  and  matters  of  speculation.  But  from  rational  hypotheses  often 
spring  great  conclusions  and  discoveries ;  and,  therefore,  we  recommend  them 
to  the  consideration  of  the  profession. — British  Medical  Journal,  July  12  and 
26,  1862. 

15.  A  Disease  like  Measles  produced  by  an  Unusual  Cause. — Dr.  Henry 
Kennedy  relates  (Dublin  Quarterly  Journal  of  Medical  Science,  Feb.  1863) 
the  following  case,  which,  at  the  time  of  its  occurrence,  he  says,  he  "was  in  total 
ignorance  of  its  nature,"  and  set  it  down  as  anomalous.  So  matters  stood  until 
he  read  the  paper  of  Dr.  Salisbury,  published  in  the  July  number  of  this  Journal 
for  last  year.  This  paper  he  regards  as  throwing  light  upon  the  origin  of  the 
disease  in  his  case. 

This  case  w*s  briefly  as  follows : — 

"A  young  gentleman  of  fifteen  years  of  age,  rather  under-sized,  but  of  a  high 
order  of  intelligence,  returned  to  school  after  the  summer  holidays,  being  then 
in  perfect  health.  As  he  entered  the  school-room  one  of  his  playmates  met  him, 
holding  a  paper  bag,  with  some  kind  of  powder  in  it,  in  his  hand,  and  before  he 


1863.]  Medical  Pathology  and  Therapeutics.  475 

was  aware,  had  dashed  a  handful  of  the  powder  in  his  face  ;  and  there  can  be  no 
doubt  that  some  of  it  got  not  only  into  his  eyes,  but  down  his  throat — for  he  was 
laughing  at  the  moment.  The  powder  turned  out  to  be  flaxseed-meal,  which, 
by  some  accident,  the  other  boy  had  found  in  the  room. 

"  The  result  was  truly  remarkable ;  the  boy  was  at  once  seized  with  smarting 
and  watering  of  the  eyes,  running  from  the  nose,  cough,  and  dyspnoea.  With 
some  difficulty  he  made  his  way  home — a  distance  of  an  English  mile.  By  the 
time  he  reached  it  his  face  had  become  much  swollen,  the  eyelids  and  eyes  very 
red,  and  the  dyspnoea  urgent.  The  excitement,  too,  of  the  system  generally  was 
very  great ;  and  all  this  within  two  hours  of  the  accident.  When  seen  the  fol- 
lowing day  he  had,  except  the  rash,  all  the  look  of  a  boy  suffering  from  a  sharp 
attack  of  measles.  His  face  was  still  swollen,  his  eyes  were  injected,  and  had  a 
strange  dark-red  line  round  them,  giving  a  very  peculiar  expression  to  the  coun- 
tenance ;  and  he  had  a  constant  loud  cough,  with  dyspnoea.  His  pulse  was  120. 
Two  years  previously  I  had  attended  him  in  a  well-marked  attack  of  measles, 
with  cough. 

"  On  hearing  the  history  of  the  case,  I  confess  I  thought  that  quiet  and  a  little 
time  would  suffice  to  get  him  well ;  and  so  he  was  only  directed  to  inhale  the 
steam  of  boiling  water ;  and,  as  his  distress  was  referred  mainly  to  the  larynx,  a 
small  mustard  poultice  was  directed  to  be  applied  over  that  organ  night  and 
morning.  In  this  expectation,  however,  I  was  much  disappointed ;  and  finally, 
after  waiting  a  few  days,  when  a  considerable  amount  of  general  bronchitis  had 
supervened,  I  was  compelled  to  treat  the  case  as  if  it  were  ordinary  measles,  by 
salines,  including  tartar  emetic,  and  blisters ;  and  by  the  end  of  three  weeks,  and 
not  till  then,  could  he  be  pronounced  well.  The  last  symptom  which  remained 
was  dyspnoea ;  for  this  he  got  small  doses  of  the  oxide  of  zinc  with  markedly 
good  effect.    The  boy  is  now  perfectly  well." 

Dr.  Kennedy  considers  that  Dr.  Salisbury  has  opened  up  a  question  of  the 
greatest  interest  and  extent,  and  he  regards  the  experiments  of  Dr.  S.  as  con- 
clusive, that  certain  bodies  which  are  being  constantly  generated  in  vegetable 
matter,  are  capable  of  causing  certain  diseases  when  inoculated  in  the  human 
frame,  or  brought  even  only  in  contact  with  mucous  membranes. 

Dr.  K.  thinks  that  the  following  deductions  may  be  drawn  from  the  facts 
which  have  been  adduced  : — 

"1.  That  certain  acute  diseases  affecting  the  throat  and  air  passages  may  be 
caused  either  by  inoculation  of  certain  vegetable  fungi  or  by  direct  contact  of 
the  same  with  the  mucous  membranes. 

"2.  That,  as  far  as  is  yet  known,  the  diseases  so  produced  seem  to  have  the 
closest  resemblance  to  measles. 

"3.  That  the  vegetable  fungi  which  have  been  long  admitted  to  exist  in  cer- 
tain chronic  diseases,  as  those  of  the  skin,  show  an  impaired  state  of  the  consti- 
tution ;  and  hence  the  importance  of  combining  a  constitutional  with  a  local 
treatment  in  their  management. 

"4.  That  when  vegetable  fungi  cause  disease  by  coming  in  contact  with  the 
mucous  membranes  of  the  head  and  chest,  we  have  now  fixed  data  for  the 
administration  of  emetics ;  which,  by  their  direct  effects,  may  thus  cut  short 
disease  in  its  early  stage." 

16.  Diseases  produced  by  bad  Potable  Water. — M.  Bouchard  at  has  com- 
municated to  the  French  Academy  some  elaborate  investigations  on  this  sub- 
ject. The  following  are  the  more  salient  facts  and  conclusions  at  which  this 
persevering  observer  has  arrived: — 

Endemic  cretinism  is  principally  due  to  two  causes  acting  simultaneously, 
viz.,  the  connection  of  cretinism  with  endemic  bronchocele  and  consanguinity 
of  marriages.  In  all  localities  where  endemic  cretinism  has  been  observed, 
endemic  bronchocele  is,  likewise,  met  with ;  thus,  in  the  Himalaya  Mountains, 
in  the  Andes,  the  Pyrenees,  and  the  Alps — in  these  parts  people  affected  with 
goitre  have  cretinous  children,  and  the  progeny  of  these  latter  are  cretins.  The 
intermediate  degree  of  "cretinous"  may  be  wanting,  but  only  in  exceptional 
cases.  In  order  that  endemic  bronchocele  may  be  developed,  a  few  years',  nay, 
even  a  few  months'  use  of  bad  drinking-water  may  suffice,  but  that  cretins  may 


476 


Progress  op  the  Medical  Sciences.  [April 


be  produced,  it  is  necessary  that  insalubrious  conditions  should  extend  over 
several  generations.  Amongst  these  influences  marriages  of  consanguinity 
between  people  who  have  been  subject  to  the  action  of  bad  drinking-water  are 
the  most  powerful.  This  hypothesis  explains  the  considerable  influence  exer- 
cised by  the  -configuration  of  the  soil.  We  observe  cretins  in  closed  valleys, 
which  have  little  communication  with  the  world  without:  the  inhabitants  of 
such  localities  intermarry  ;  and  even  if  all  the  marriages  should  not  be  decidedly 
consanguineous,  they,  nevertheless,  take  place  most  frequently  amongst  people 
who  have  been  subject  to  the  same  influences.  For  such  degenerate  races  con- 
sanguinity is  full  of  danger.  M.  Bouchardat  was  formerly  of  opinion  that  con- 
sanguinity was  not  noxious  to  persons  otherwise  well  developed  ;  and  believed 
that,  although  certain  inconveniences  might  be  connected  with  it,  these  were 
compensated  by  the  increase  of  beauty  and  purity  of  race.  This  opinion  was 
founded  on  certain  facts  in  zoology,  and  on  the  circumstance  that,  in  ancient 
Greece,  the  most  perfect  types  of  humanity  had,  under  the  influence  of  consan- 
guineous alliances,  become  rather  improved  than  deteriorated.  His  convictions, 
however,  have  been  shaken  by  M.  Boudin's  researches  on  the  influences  of  such 
marriages  in  producing  deaf-and-dumbness ;  and  he  will,  probably,  give  up  this 
idea  altogether  if  he  should  become  acquainted  with  M.  Liebreich's  investiga- 
tions on  "  retinitis  pigmentosa,"  as  caused  by  the  same  influence,  and  which 
seem  to  have  hitherto  escaped  M.  Bouchardat's  attention. 

In  order  to  prevent  cretinism,  public  and  private  hygienic  measures  should 
be  taken.  As  regards  the  individuals  affected,  they  should  be  removed  from 
the  localities  where  endemic  goitre  and  cretinism  are  found  to  exist,  and  trans- 
ferred to  a  moral,  intelligent,  and  humane  household,  where  they  should  be 
under  continued  surveillance.  They  ought  not  to  be  left  to  a  degrading  inac- 
tion, but  those  faculties  which  are  given  them  should  be  brought  into  play. 
With  respect  to  public  hygiene,  we  must  keep  in  mind  the  fact,  that  cretinism 
has  been  diminished,  or  even  altogether  disappeared,  as  soon  as  a  broad  high 
road  has  intersected  the  places  in  question,  and  they  have  been  animated  by 
commerce.  They  should,  therefore,  be  cut  through,  not  by  railways,  but  by 
roads,  leading  to  a  healthy  population  into  the  localities,  and  thereby  diminish- 
ing the  chance  of  marriages  of  consanguinity.  The  church  should  only  give 
licences  for  such  marriages  with  the  very  greatest  caution.  Gin-shops  should 
be  placed  under  strict  surveillance  ;  and  all  should  be  rigorously  punished  who 
would  sell  alcoholic  liquors  to  children,  or  to  beings  devoid  of  reason. 

In  France,  and  on  the  Continent  generally,  persons  affected  with  goitre,  and 
having  a  disposition  to  cretinism,  are  exempt  from  military  service ;  but  M. 
Bouchardat  is  inclined  to  think  that,  by  recruiting  amongst  such  persons  for 
the  army,  we  should  render  them  the  most  essential  services.  The  change  of 
place,  the  attention  that  would  be  given  them  by  the  army  surgeons,  etc.,  would 
soon  free  them  from  their  infirmity ;  while  military  discipline  would  raise  the 
level  of  their  intelligence,  and,  in  subjecting  them  to  the  "  reign  of  rule,"  would 
make  useful  men  of  them.  Another  consideration  here  would  be,  the  ameliora- 
tion of  race.  If  bronchocele  is  the  first  step  leading  to  cretinism,  it  is  obvious 
that,  if  the  6lite  of  the  population  is  taken  away  by  conscription,  persons  with 
bronchocele,  who  are  exempt,  will,  as  it  were,  monopolize  the  country,  and  con- 
dense the  focus  of  the  evil.  Thus  conscription,  which  for  these  localities  might 
be  a  condition  of  progress,  if  it  removed  those  affected  in  order  to  bring  them 
back  cured,  becomes,  on  the  contrary,  one  of  the  most  active  causes  of  degene- 
ration. Persons  of  the  kind  mentioned  might  do  good  duty  in  military  infirma- 
ries and  other  branches  of  the  army  and  navy.  If  transferred  to  this  latter,  the 
mere  circumstance  of  living  in  a  port  or  on  the  sea  would  effect  a  speedy  and 
definite  cure.  The  last  word  of  advice,  however,  to  the  authorities  is — give 
these  localities  wholesome  water.  Everywhere  you  may  collect  rain-water  in 
sufficient  quantity  for  the  wants  of  man.  Distribute,  moreover,  to  the  popula- 
tions of  such  districts  salines,  with  a  small  proportion  of  iodine,  so  that  each 
person  may  take  a  few  milligrammes  of  iodine  every  day,  proper  medical  atten- 
tion being  at  the  same  time  necessary.  Drinking-water,  the  continued  use  of 
which  causes  the  formation  of  endemic  goitre  and  cretinism,  contains  organic 
substances  in  solution  which  come  from  the  decomposition  of  certain  vegetable 


1863.]         Medical  Pathology  and  Therapeutics.  4T7 

parts  in  dolomitic  soil.  Such  water  generally  comes  from  ponds,  marshes,  fens, 
and  swamps,  and  should  never  be  taken  unless  previously  filtered  or  boiled. 

The  "bouton"  of  Aleppo,  and  the  "bouton"  of  Biskra,  two  endemic  diseases 
of  the  skin  which  are  still  enveloped  in  much  obscurity,  are  in  all  probability 
produced  by  the  use  of  unwholesome  drinking-water.  All  those  who  drink  of 
the  water  of  Ooick  for  a  certain  time  become  affected  with  the  "bouton"  of 
Aleppo,  while  those  who  do  not  partake  of  it  are  spared.  The  country  people 
who  come  to  the  town  of  Aleppo  and  drink  of  the  bad  water  soon  begin  to 
suffer;  while  those  peasants  who  stop  at  home  remain  free.  The  water  of 
Coick  is  slightly  alkaline,  and  contains  the  salines  usually  found  in  drinking- 
water,  as  well  as  organic  matter,  which  latter  is  no  doubt  the  cause  of  the  evil. 
The  "  bouton"  of  Biskra,  which  very  much  resembles  that  of  Aleppo,  is  to  be 
ascribed  to  the  use  of  the  water  of  a  torrent  coming  from  a  plain  where  the 
remains  of  more  than  a  hundred  thousand  palm-trees  are  accumulated.  It  is 
highly  probable  that  the  organic  substances  coming  from  the  decomposition  of 
these  remains,  under  the  influence  of  salines  in  solution,  impart  this  remarkable 
property  to  the  water. 

The  following  are  the  chief  hygienic  characters  of  the  different  species  of 
drinking-water : — 

1.  Spring-water  has  the  advantage  of  being  generally  limpid,  so  that  there  is 
no  occasion  for  filtration,  and  of  being  fresh  and  agreeable  to  drink;  springs 
come,  moreover,  frequently  from  a  higher  elevation  than  the  towns  where  they 
are  used,  so  that  we  do  not  want  mechanical  contrivances  for  raising  the  water. 
Spring-water  is  mostly  richer  in  salines  than  river-water.  If  it  is  pleasant  to 
drink,  and  if  the  fixed  constituents  consist  of  bicarbonate  of  lime  without  organic 
matters,  and  with  oxygen,  the  water  is  extremely  salubrious ;  but  if  it  contains 
organic  substances,  if  it  comes  from  marshy  soil,  and  is  devoid  of  oxygen,  it 
must  be  looked  upon  with  distrust,  in  spite  of  the  good  appearance  it  may  pre- 
sent. Water  of  this  kind  should  only  be  used,  if  the  experience  of  several  gene- 
rations has  fully  proved  its  innocuity.  This  is  of  much  more  importance  than 
any  chemical  analysis,  however  well  made. 

2.  Water  of  rivers  and  rivulets  is  generally  wholesome,  but  its  composition 
may  slightly  vary  according  to  high  or  low-water,  and  this  is  not  the  smallest 
disadvantage  it  offers.  It  requires  to  be  filtered,  and  in  summer  to  be  cooled  ; 
and  the  poor  man  has  no  filter  for  purifying,  and  no  cellar  for  cooling  the  water. 

3.  Water  of  canals  usually  contains  more  fixed  constituents  than  river-water, 
and  also  organic  matter. 

4.  Water  of  wells  in  old  towns  is  almost  always  saturated  with  sulphate  of 
lime ;  it  contains,  moreover,  the  last  products  of  decomposition  of  organic  sub- 
stances, amongst  which  we  find  nitrates  and  compounds  of  ammonia,  which 
arise  from  putrid  fermentation  of  bodies  interred  in  cemeteries,  and  other  im- 
purities. 

5.  Water  of  cisterns,  accumulated  by  rain,  is  generally  pure,  unless  collected 
from  roofs  soiled  by  dust  or  soot.  This  water  is  almost  too  pure,  and  the 
absence  of  lime  is  prejudicial  in  certain  conditions,  as,  for  instance,  for  wet- 
nurses,  young  children,  etc.  This  want  should,  therefore,  be  filled  up.  Rain- 
water combines  with  lead,  and  we  should,  on  no  account,  collect  it  in  cisterns  of 
lead,  or  raise  it  by  pumps  in  the  construction  of  which  lead  has  been  employed. 

6.  Water  of  marshes,  ponds,  swamps,  fens,  etc.,  is  generally  bad,  because  it 
contains  a  considerable  proportion  of  organic  substances  in  suspension  and 
solution.  If  one  is  obliged  to  drink  water  of  this  kind,  it  is  preferable  to  choose 
such  only  as  has  undergone  the  influence  of  the  sun,  and  which  contains  red  or 
green  monads.  If  possible,  it  should  be  filtered  through  carbon,  and  only  be 
employed  after  having  been  boiled.  As  boiled  water,  by  itself,  is  unpleasant  to 
drink,  tea  or  coffee  should  be  added,  or,  if  these  substances  cannot  be  procured, 
roots  of  the  strawberry  plant,  leaves  of  holly,  oak,  soap-wort,  sage,  mint, 
thyme,  etc. — Med.  Times  and  Gaz.,  Feb.  14,  1863. 

17.  Epidemic  from  Eating  the  Meat  of  a  Diseased  Cow. — Dr.  Husemann, 
of  Detmold,  gave  an  account  to  the  Congress  of  German  Naturalists  and  Phy- 
sicians, of  a  new  epidemic  disease,  which  had  been  observed  by  him  in  August, 


478  Progress  of  the  Medical  Sciences.  [April 

1862,  and  was  caused  by  eating  the  flesh  of  a  diseased  cow.  About  150  persons 
were  affected.  The  epidemic  was  novel  in  etiology  as  well  as  with  regard  to 
the  symptoms.  There  were  three  forms  of  it:  one  was  very  mild,  the  patients 
suffering  from  diarrhoea  without  fever ;  another  was  more  severe;  there  being 
rigors,  febrile  symptoms,  vomiting,  diarrhoea,  cerebral  symptoms,  and  violent 
pains  in  the  abdomen,  with  great  sensitiveness  to  pressure;  the  symptoms  con- 
tinued for  about  a  week.  The  third  form  was  the  most  severe;  there  was 
general  collapse,  coldness  of  the  extremities,  scarcely  perceptible  pulse,  etc. 
Death  ensued  in  three  cases,  and  convalescence  was  much  protracted  in  the 
others.  The  post-mortem  appearances  were  gastro-enteritis,  and  hyperemia 
and  extravasation  in  the  cerebral  meninges,  the  blood  being  dark  and  very  fluid. 
There  was  no  retention  of  urine,  and  no  difficulty  of  deglutition,  whereby  the 
epidemic  was  distinguished  from  cholera,  and  from  poisoning  with  sausages. 
The  cow  had  had  a  fracture  of  the  ribs  and  pleurisy,  and  it  was,  therefore, 
probable  that  the  meat  had  been  poisoned  in  consequence  of  pyaemia.  The 
meat  was  poisonous  whether  roasted  or  boiled. — Med.  Times  and  Gaz.,  Dec.  13, 
1862. 

18.  Cerebral  Hemorrhage. — Mr.  Jones  read  (January  16,  1863)  before  the 
Western  Medical  and  Surgical  Society  an  account  of  his  researches  relative  to 
some  points  in  connection  with  cerebral  hemorrhage.  The  author's  conclusions 
were  based  upon  40  fatal  cases  which  had  occurred  at  St.  George's  Hospital. 
These  were  taken  indiscriminately;  but  after  a  careful  scrutiny,  selecting  only 
those  cases  in  which  a  perfect  post-mortem  examination  of  all  the  organs  of  the 
body  took  place,  and  in  which  a  visible  hemorrhage  could  be  demonstated  from 
the  cerebral  arteries,  36  cases  were  found  perfectly  reliable  for  his  remarks.  Of 
the  predisposing  causes,  the  influence  of  age  was  first  discussed,  and,  contrary 
to  what  had  been  often  advanced,  he  showed  that  the  greater  number  of  cases 
occurred  between  the  ages  of  40  and  50 ;  for  in  38  cases  he  had  found  3  had 
occurred  between  30  and  40  years,  13  between  40  and  50, 10  between  50  and  60, 
9  between  60  and  70,  and  3  between  70  and  80.  But  a  further  examination 
showed  that,  by  comparing  the  numbers  of  cases  with  the  respective  numbers 
of  population  at  similar  ages,  the  period  of  life  at  which  the  disease  was  most 
prone  to  occur  relatively  was  between  60  and  70 ;  for  between  30  and  40  years, 
3  cases  occurred  in  a  population  of  2500 ;  between  40  and  50,  13  cases  in  a 
population  of  1800;  between  50  and  60,  10  cases  in  1300;  between  60  and  70, 
9  cases  in  1000 ;  and  between  70  and  80,  3  cases  in  a  population  of  500.  With 
regard  to  sex,  males  were  shown  to  be  more  liable  to  the  disease  than  females  ; 
for  of  40  cases  11  only  were  females.  Mr.  Jones  next  described  the  efficient 
causes  of  cerebral  hemorrhage,  and  the  intimate  connection  between  the  latter 
and  disease  of  the  kidneys,  heart,  and  arteries.  This  being  one  of  the  principal 
objects  of  the  paper,  he  entered  minutely  into  details  of  the  36  fatal  cases  in 
which  disease  of  the  kidneys,  the  heart,  or  arteries  was  found  conjointly  or  singly 
with  cerebral  hemorrhage.  The  analysis  of  these  36  cases  was  then  examined, 
the  result  being  that  disease  of  the  cerebral  vessels,  other  vessels,  of  the  heart, 
of  the  kidneys,  was  found  in  conjunction  10  times ;  disease  of  the  cerebral  ves- 
sels, of  the  heart,  of  the  kidneys,  22  times  ;  disease  of  the  heart  and  kidneys,  29 
times ;  of  the  cerebral  vessels  and  kidneys,  22  times ;  of  the  cerebral  vessels  and 
heart,  24  times;  of  the  cerebral  vessels  and  heart  (hypertrophy),  10  times;  of 
vessels  not  cerebral  and  kidneys,  13  times ;  of  vessels  not  cerebral  and  heart, 
13  times.  The  further  result  of  the  analysis  showed  that  in  more  than  one-half 
the  cases  the  kidneys,  heart,  and  cerebral  vessels  were  simultaneously  affected  ; 
and  in  almost  all  those  cases  in  which  there  was  absence  of  disease  in  one  or 
other  of  these  organs  there  was  the  history  of  an  accident  to  which  this  attack 
was  attributed.  The  various  morbid  appearances  found  in  the  kidneys,  heart, 
and  arteries,  under  the  foregoing  circumstances,  were  fully  and  minutely  ex- 
plained, the  author  being  strongly  of  opinion  that  the  diseased  condition  of  the 
kidneys  first  led  to  that  of  the  arteries,  and  subsequently  to  the  heart.  In 
support  of  this  opinion,  Mr.  Jones  offered  an  hypothesis  to  the  effect  that  the 
kidneys,  from  their  disorganized  state,  being  unable  to  depurate  the  blood  on 
the  one  hand,  but  allowing  the  albumen  to  unduly  pass  away  on  the  other,  this 


1863.]  Medical  Pathology  and  Therapeutics. 


479 


fluid  was  rendered  unfit  to  carry  on  the  nutrition  of  the  tissues,  and  that  the 
arteries  suffered  early  from  this  defective  nutrition.  The  conclusions  the  author 
drew  from  his  elaborate  examination  of  the  subject  was,  first,  that  cerebral 
hemorrhage,  when  associated  with  renal  disease,  is  almost  always  found  to  be 
dependent  upon  rupture  of  one  or  more  of  the  cerebral  arteries,  in  consequence 
of  certain  morbid  changes  having  taken  place  in  their  walls ;  secondly,  that 
these  changes  in  the  walls  of  the  vessels  are  induced  by  the  altered  state  of  the 
blood,  the  effect  of  advanced  disease  of  the  kidneys ;  and,  lastly,  that  the  en- 
largement of  the  heart  is  the  immediate  effect  of  the  renal  disease,  conjointly, 
perhaps,  with  the  alterations  in  the  coats  of  the  vessels.  The  paper  concluded 
with  some  remarks  upon  the  treatment  of  these  cases,  in  which  a  tonic  and 
stimulating  plan,  rather  than  a  lowering  one,  was  advocated,  and  two  cases  were 
given  which  seemed  to  justify  it. — Med.  Times  and  Gaz.,  Feb.  14,  1863. 

19.  Influence  of  Hypertrophy  of  the  Heart  and  Diseases  of  the  Cerebral  Arte- 
ries in  the  Production  of  Apoplexy. — Dr.  A.  Eulenburg  has  investigated  this 
subject  statistically  in  a  prize  thesis  presented  to  the  Medical  Faculty  at  Berlin. 
In  42  cases  of  sanguineous  cerebral  apoplexy,  abnormal  conditions  of  the  arte- 
ries at  the  base  of  the  brain — hardening,  calcareous  deposits,  and  fatty  degene- 
ration— were  found  in  29 :  in  13  cases  only  were  the  large  cerebral  arteries  free 
from  disease.  In  9  of  the  42  cases  there  was  hypertrophy  of  the  left  ventricle. 
Of  the  29  cases  in  which  disease  of  the  cerebral  arteries  was  present,  there  was 
also  more  or  less  extensive  endocarditis  in  17,  alterations  of  the  valves  of  the 
heart  in  19,  and  hypertrophy  of  the  left  ventricle  in  6  only.  Dr.  Eulenburg 
hence  draws  the  conclusion  that  disease  of  the  cerebral  arteries  is  a  much  more 
frequent  cause  of  apoplexy  than  cardiac  hypertrophy. — British  Medical  Jour- 
nal, Dec.  6,  1862,  from  Virchow's  Archiv,  and  Wiener  Medicin.  Wochenschr., 
Sept.  6,  1862. 

20.  Embolism. — An  interesting  case  of  embolia  of  the  infundibulum  of  the 
right  ventricle  and  pulmonary  artery  communicated  to  the  Soci6te  Anatomique, 
of  Paris,  by  M.  Gouraud,  has  been  made  the  subject  of  a  report  by  M.  Lance- 
reaux."  The  following  is  M.  Gouraud's  re'sume':  "A  healthy  woman,  aged  46 
years,  entered  La  Charity,  for  a  fracture  of  the  right  leg,  accompanied  by  con- 
siderable extravasation  of  blood.  Scutter's  apparatus  was  applied,  and  all  went 
on  well,  the  size  of  the  limb  lessening.  After  three  weeks  the  apparatus  was 
replaced  by  a  starch  bandage.  On  the  following  morning  the  patient  was  quite 
well,  but,  some  hours  later,  violent  palpitations  of  the  heart  occurred,  the  patient 
cried  out,  became  livid,  and  was  dead  in  a  few  minutes.  On  post-mortem  exa- 
mination, the  right  tibia  presented  two  solutions  of  continuity,  the  fibula  being 
fractured  in  only  one  place ;  there  was  an  extravasation  of  blood  infiltrating  the 
whole  thickness  of  the  soft  parts  in  this  region.  The  veins  of  the  right  leg  pre- 
sented small  coagula,  which  became  more  distinct  and  large  in  the  femoral  vein, 
the  external  and  common  iliac,  and  even  in  the  lower  part  of  the  vena  cava. 
The  fibrinous  coagulum  was  firm,  elastic,  of  a  deep  red  or  rose  colour,  and  was 
adherent  at  several  points  to  the  internal  surface  of  the  vessel.  On  the  left  side 
the  limb  and  veins  were  healthy.  From  the  lower  part  of  the  vena  cava  to  the 
heart  the  blood  was  liquid.  There  existed  in  the  infundibulum  of  the  right 
ventricle  and  in  the  pulmonary  artery  a  clot  drawn  out  into  the  form  of  a  leech, 
thirty-six  centimetres  in  length,  of  a  diameter  much  less  than  the  vessel  where 
it  was  found,  of  a  rose  or  deep  red  colour,  and  not  homogeneous.  The  lungs 
were  engorged,  but  crepitant."  M.  Gouraud  explains  the  obliteration  of  the 
passage  by  the  arrest  of  the  long  clot,  on  arriving  at  a  branch  of  the  pulmonary 
artery,  such  as  would  not  allow  it  to  proceed  further,  and  then  by  the  ventricular 
contractions  causing  the  other  extremity  to  be  folded  back  in  the  infundibulum, 
so  as  to  lie  opposite  the  sigmoid  valves.  It  is  necessary  that  we  should  abridge 
considerably  M.  Lancereaux's  observations.  The  first  question  to  which  he 
applies  himself  is  the  cause  of  the  coagulation  which  took  place  in  the  veins. 
He  explains  it  thus :  The  blood  coagulated  at  the  seat  of  the  fracture  necessarily 
compressed  the  mouths  of  the  ruptured  vessels ;  but,  at  the  same  time,  coagula 
would  form  at  the  extremities  of  these  vessels,  and  mount  up,  as  is  the  rule  for 


480 


Progress  of  the  Medical  Sciences. 


[April 


thein  to  do,  as  high  as  the  nearest  valves.  From  the  withdrawal  of  the  vis  a 
tergo,  there  would  be  stasis  of  the  blood  proceeding  from  the  collateral  veins,  a 
new  coagulum,  commencing  this  time  at  the  valves,  and  these  latter  coagula 
would  lengthen  gradually,  and  become,  in  their  turn,  the  cause  of  new  coagula, 
until  the  principal  venous  trunk  becomes  completely  obstructed.  In  this  view 
the  cause  is  a  local  one,  namely,  the  diminution  of  the  current  of  blood,  and  the 
influence  exercised  by  the  fibrinous  clot  upon  the  blood  which  surrounds  it. 
Admitting  the  sufficiency  of  this  cause  to  produce  venous  coagulation,  other 
causes  may  be  added,  such  as  diminution  or  loss  of  contractile  power  in  the 
veins,  tumours  compressing  them,  and  whatever  retards  the  venous  circulation. 
General  causes  would  also  operate,  on  the  one  hand,  by  lowering  the  force  of 
the  heart  and  the  contractility  of  the  vessels,  and,  on  the  other,  by  causing 
modifications  in  the  blood  itself  such  as  are  even  now  little  understood.  It  is 
important  to  point  out  that,  under  the  influence  even  of  general  causes,  it  is 
always  where  the  circulation  tends  to  be  slow  that  coagulation  commences. 

The  clot,  which  begins  to  be  formed  at  the  situation  of  a  valve,  presents  a 
form  and  characters  which  must  first  be  treated  of.  At  one  extremity  it  pre- 
sents the  mould  of  one  or  two  of  the  valves ;  its  other  end  is  rounded  or  conical, 
and  upon  its  length  may  be  perceived  the  smooth  and  clean  impressions  of 
valves.  One  of  its  surfaces,  that  in  contact  with  the  wall,  is  strictly  striated, 
yellowish  or  marbled  ;  the  other  surface,  free  and  bathed  in  the  blood,  is  brown- 
ish and  granular.  The  length  varies  from  some  millimetres  to  several  centi- 
metres ;  its  bulk  may  become  considerable,  since  it  generally  forms  in  the  largest 
vessels,  and  is  thus  the  most  frequent  cause  of  sudden  deaths.  Besides,  by 
reason  of  its  characters,  it  constitutes  the  most  positive  evidence  of  embolia  of 
the  pulmonary  artery  when  it  is  met  with  in  this  entirely  valveless  vessel.  Ob- 
servation teaches  us  that,  where  there  is  but  one  clot,  and  the  death  has  been 
sudden,  it  is  always  the  trunk  of  the  pulmonary  artery  or  the  infundibulum  which 
is  found  obstructed.  The  blood  in  the  heart  is  ordinarily  black  and  fluid,  as  in 
death  by  asphyxia.  I  do  not,  for  my  own  part,  think  that  a  single  embolus, 
arrested  in  one  of  the  divisions  of  the  artery,  can  bring  about  this  fatal  accident. 
For  the  most  part  the  embolic  clots  are  multiple,  and  always,  I  say  again,  if 
death  has  been  rapid,  they  are  found  either  in  the  trunk  of  the  pulmonary  artery 
or  in  its  principal  branches.  As  respects  the  smallest  clots,  they  are  rarely 
found  in  divisions  of  the  fifth  order,  but  mostly  in  those  of  the  third  or  fourth. 
In  some  special  cases  known  as  capillary  emboli,  very  small  clots  have  been 
found  in  the  smallest  branches.  The  form  of  the  migratory  clots  is  generally 
cylindrical,  their  extremities  at  one  time  regular,  smooth,  and  conical ;  at  another, 
rough  and  torn ;  at  another,  only  one  end  is  torn,  while  the  other  is  polished 
and  conical.  It  is  in  cases  where  both  extremities  are  smooth  and  untorn  that 
valvular  impressions  are  found  upon  the  body  of  the  clot,  and  one  or  two  moulds 
of  valves  at  one  extremity.  The  clots  which  are  torn  at  their  extremities  are 
generally  devoid  of  impression  and  moulds,  but  they  are  now  and  then  chan- 
nelled. 'When  one  extremity  only  is  torn,  the  other  is  generally  conical'.  The 
same  difference  which  we  have  established  in  the  characters  of  venous  clots  is, 
consequently,  found  in  the  clots  of  the  pulmonary  artery;  and  there  exists 
between  the  venous  coagula  and  those  of  the  pulmonary  artery  such  a  resem- 
blance, that  we  are  compelled  to  admit  that  the  clots  have  been  transported 
from  the  veins  into  this  artery. 

Besides  these  characters,  embolic  clots  differ  from  coagula  formed  just  prior 
to  or  immediately  after  death  in  their  elasticity,  brownish  or  marbled  colour, 
and  the  condition  of  the  fibrin  which  is  always  in  progress  of  retrogression. 
The  clots  formed  at  death  are  soft,  cedematous,  flattened,  branched,  and  only 
close  incompletely  the  containing  vessel.  The  clots  which,  during  life,  form 
primarily  in  the  branches  of  the  pulmonary  artery  (autochthones),  differ  from 
emboli  in  their  form  and  seat,  and  in  the  absence  of  the  characters  which  have 
been  described.  In  certain  circumstances,  however,  they  are  readily  confounded 
with  embolic  clots,  namely,  where  fibrinous  coagula  have  become  added  to  the 
latter,  but  it  is  always  easy,  by  means  of  a  section  and  examination  with  the 
microscope,  to  recognize  the  central  embolus.  If  the  bulk  of  embolic  clots  is 
very  variable,  their  length  especially  presents  great  variety:  thus,  whilst  some 


1863.] 


Medical  Pathology  and  Therapeutics. 


481 


may  only  measure  a  few  millimetres,  others  are  several  centimetres  in  length  ; 
such  as  I  have  seen  produce  sudden  death,  have  been  five  centimetres  long;  that 
which  M.  Gouraud  has  described  in  his  observation  presented  the  extraordinary 
length  of  thirty-six  centimetres.  I  am  disposed  to  believe  that  some  error  has 
slipped  into  this  measurement,  especially  seeing  that  the  femoral  and  part  of  the 
iliac  veins  were  filled  with  a  fibrinous  coagulum.  Under  these  circumstances  it 
is  necessary  to  suppose  that  the  embolic  clot  occupied  primarily  the  greater 
extent  of  the  vena  cava,  a  hypothesis  of  little  probability,  since  no  symptom  of 
such  an  obstruction  waa  apparent  during  life.  I  am,  consequently,  driven  to 
believe  that  some  secondary  coagulations  have  been  comprised  in  the  measure- 
ment. But  be  this  as  it  may.  it  is  certain  that  very  long  clots  may  be  carried 
by  the  torrent  of  the  circulation,  and  an  important  and  peculiar  character  of 
them  is,  that  they  are  curved  and  wound  round,  at  one  time  in  the  trunk  of  the 
pulmonary  artery,  and  in  the  infundibulum.  as  in  M.  Gouraud's  case — at  another, 
in  one  of  the  principal  divisions  of  the  pulmonary  artery.  But  after  a  certain 
lap?e  of  time  these  distinctive  characters  become  wanting,  and  it  is  then  very 
difficult  to  tell  whether  a  coagulum,  met  with  in  the  pulmonary  artery,  has  been 
formed  there,  or  has  arrived  there  by  migration.  The  only  circumstance  which 
we  may  thus  be  able  to  call  up  in  favour  of  embolus,  is  the  existence  of  a  venous 
thrombus.  The  phenomenon  which  renders  the  embolus  unrecognizable  is  im- 
portant and  really  remarkable.  The  continued  contact  of  the  clot  with  the 
arterial  wall  determines  a  slight  irritation,  in  virtue  of  which  a  blastema,  exuded 
between  the  wall  of  the  vessel,  and  the  clot,  soon  becomes  organized ;  by  degrees, 
this  substance  extends  on  the  circumference  of  the  plug,  and  soon  forms  a  sort 
of  cupule,  in  which  the  latter  is  contained.  At  last  it  envelops  it  completely, 
and  encysts  it,  so  that,  after  a  time,  often  not  very  long,  the  fibrinous  coagulum 
of  the  pulmonary  artery  is  found  to  be  everywhere  surrounded  by  a  perfectly 
organized  membrane.  Within  this  membrane,  microscopic  examination  dis- 
covers an  amorphous  substance,  more  or  less  granular,  embryo-plastic  nuclei, 
elongated  cells,  and,  above  all,  fibres  of  connective  tissue.  In  the  midst  of  these 
elements  we  sometimes  find  capillaries,  free  granules,  the  debris  of  red  globules, 
and  amorphous  and  crystalline  haematin.  After  describing  further  changes  in 
the  condition  of  these  encysted  clots,  M.  Lancereaux  proceeds  to  the  subject  of 
the  condition  of  the  lungs  in  cases  of  pulmonary  embolia.  It  is  evident  (he  con- 
tinues) that  an  embolus  which  closes  up  the  trunk  of  the  pulmonary  artery,  and 
gives  rise  to  sudden  death,  cannot  cause  any  important  disorder  in  the  pulmo- 
nary parenchyma.  Supposing  such  alteration  possible,  time  would  be  wanting. 
But  it  is  different  when  a  coagulum  comes  to  be  situated  in  an  important  divi- 
sion of  the  artery,  closing  its  canal  completely.  In  this  respect,  M.  Lancereaux 
expresses  his  agreement  with  Virchow,  who  states  that,  however  complete  the 
obstruction,  it  produces  no  alteration  in  the  parenchyma,  and,  above  all,  no 
gangrene  of  the  lungs.  At  the  most,  Lancereaux  has  observed  slight  diminution 
of  volume,  anaemia,  or  some  oedema ;  and  he  explains  this,  physiologically,  by 
the  fact,  that  the  pulmonary  artery  is  an  organ  engaged  in  ha?matosis,  and  that 
the  nutrition  of  the  lung  is  effected,  not  by  this,  but  by  the  bronchial  arteries. 
Still  (he  proceeds  to  say)  pulmonary  coagula  are  sometimes  accompanied  by  a 
lesion  of  the  parenchyma  of  the  lungs,  whether  they  be  the  cause  of  it  or  not. 
Pulmonary  apoplexy  is  frequently  conjoined  with  obstruction  of  the  branches 
of  the  artery;  but  it  is  to  be  remembered,  that  this  generally  occurs  in  the 
course  of  affections  of  the  heart,  especially  in  fatty  degeneration ;  and  it  is  also 
to  be  observed,  that,  under  these  circumstances,  the  clot  is  always  situated 
behind  the  apoplectic  spot,  has  none  of  the  characters  of  an  embolic  clot,  and 
is  evidently  autochthonic — not  the  cause,  but  an  effect,  of  the  apoplexy.  The 
same  thing  may  happen  in  certain  cases  of  tubercular  disease,  of  pneumonia,  or 
even  of  gangrene.  It  is,  however,  important  to  notice,  that  there  are  certain 
special  conditions  of  the  embolic  clot  which  are  capable  of  giving  rise  to  two  of 
the  alterations  just  alluded  to — namely,  pneumonia  and  gangrene.  These  con- 
ditions pertain  to  a  special  state  of  alteration  of  the  tissues,  in  the  midst  of  which 
the  thrombus  has  been  formed :  if  the  coagulation  has  taken  place  in  the  midst 
of  a  purulent  or  gangrenous  focus,  the  coagulum,  formed  in  part  of  fibrin,  and 
in  part  of  other  elements,  possesses  qualities  in  virtue  of  which  it  may  alter  the 
No.  XC.-— April  1863.  31 


482 


Progress  of  the  Medical  Sciences. 


[April 


tissues  with  winch  it  subsequently  comes  in  contact ;  thus  it  is  that  metastatic 
abscesses  often  appear  in  the  lungs  of  individuals,  with  suppurative  thrombus 
of  the  cerebral  sinuses,  and  in  women  suffering  from  metritis  or  suppurative  phle- 
bitis. Thus,  too,  gangrenous  spots  in  the  brain  are  found  in  persons  who  have 
primarily  a  gangrene  of  the  lung ;  and  gangrene  of  the  lungs  is  met  with  fre- 
quently in  paralytic  individuals,  in  whom  a  sphacelus  has  formed  over  the  region 
of  the  sacrum.  Particles  of  fibrin  or  fragments  of  tissue,  impregnated  with  pus 
or  septic  matters,  become  the  points  of  origin  of  secondary  foci,  purulent  or 
gangrenous,  as  the  case  may  be.  • 

Certain  practical  conclusions  flowing  from  this  fact  related  by  M.  Gouraud 
deserve  attention.  We  find  here  a  condition  which  has  already  been  mentioned 
in  other  cases,  one  of  which  is  related  by  Klinger.  In  three  different  cases  sud- 
den death  has  followed  shortly  upon  compression  exercised  by  a  bandage  upon 
the  limb,  which  is  the  subject  of  the  thrombus.  It  was,  as  we  know,  formerly 
customary  to  apply  a  compressing  bandage  upon  a  limb  affected  with  oedema, 
or  even  with  phlebitis,  as  soon  as  the  acute  stage  of  the  inflammation  had  ceased. 
The  practice  is  far  from  being  free  from  danger,  and  it  must  necessarily  be  pro- 
scribed. But,  besides,  when,  consecutively  to  a  traumatic  condition,  fracture, 
amputation,  etc.,  we  have  reason  to  suspect  the  existence  of  a  venous  thrombus, 
it  will  surely  be  prudent  in  the  surgeon  to  abstain  as  much  as  possible  from 
strong  compression,  if  he  would  not  expose  his  patient  to  more  or  less  serious 
accidents.  It  is  especially  some  time  after  the  commencement  of  the  coagula- 
tion, when  the  fibrin  begins  to  disintegrate,  that  we  must  avoid  this  practice. 
And,  for  the  same  reason,  every  kind  of  handling  of  the  injured  limb  should  be 
avoided,  and  the  most  complete  state  of  rest  maintained.  Indeed,  in  a  certain 
number  of  cases,  a  slightly  exaggerated  effort,  as  I  have  seen  on  two  different 
occasions,  may  suffice  to  bring  about  the  separation  of  the  clot,  and  sudden 
death.  Occasional  causes  of  this  kind  are  marked,  in  the  greater  number  of 
cases  of  sudden  death,  by  embolia,  and  it  is  thus  pointed  out  how  necessary  it 
is  to  be  cautious  when  we  have  to  do  with  patients  suffering  from  venous  throm- 
bus.— Med.  Times  and  Gaz.,  Feb.  14,  1863. 

21.  Conditions  affecting  the  Constitution  of  Phthisical  Persons  when  in 
Health. — Dr.  Edward  Smith,  Assistant  Physician  to  the  Hospital  for  Con- 
sumption and  Diseases  of  the  Chest,  has  published  [Dublin  Quarterly  Journal 
of  Medical  Science,  February,  1863)  a  very  interesting  statistical  inquiry  into 
the  prevalence  of  numerous  conditions  affecting  the  constitution  in  10,000 
phthisical  persons  when  in  health ;  intended  to  show  the  prevalence  of  a  large 
number  of  conditions  which  are  believed  to  modify  the  constitution,  or  which 
are  evidences  of  modified  constitutions  in  consumptive  families.  The  investi- 
gation extended  to  a  very  large  number  of  questions,  and  the  results  are  given 
in  separate  tables. 

The  author  gives  the  following  summary  of  the  leading  truths  which  his 
extended  investigation  suggests  : — 

"The  first  question  which  arises  is  that  of  hereditary  transmission,  either  in 
the  sense  of  absolute  transfer  of  the  elements  of  the  particular  disease  from  the 
parent  to  the  child,  or  the  communication  of  a  state  of  the  system  in  which  dis- 
ease in  general,  and  this  disease  in  particular,  may  probably  originate.  There 
is  a  wide  difference  in  these  two  ideas,  and  yet  it  cannot  be  doubted  that  they 
both  exist  in  the  minds  of  various  professional  men  at  this  day.  The  former  is 
the  older  one,  and  that  which  the  increasing  knowledge  of  our  day  has  rendered 
less  tenable  than  was  formerly  believed,  since  the  idea  of  the  transmission  of  the 
germs  of  disease  in  utero  is  now  more  strictly  limited  to  such  specific  diseases 
as  syphilis.  Yet  it  must  be  admitted,  that  whilst  the  growing  feeling  of  the  day 
is  in  favour  of  a  theory  which  only  implies  a  defective  constitution,  there  is  an 
under  current  of  belief  that  this  assumes  a  specific  direction  in  the  production 
of  this  particular  class  of  disease.  Hence,  whilst  there  is  a  clear  distinction  in 
the  two  theories  in  statement,  there  is  far  more  oneness  in  belief.  We  will  look 
at  them  in  both  aspects. 

"Feebleness  of  the  general  health  of  the  parents  existed  before  the  birth  of 
the  patient  in  one-fifth,  and  throughout  life  in  one-third  of  all  the  cases.    It  is 


1863.]  Medical  Pathology  and  Therapeutics. 


483 


quite  certain  that  the  former  statement  would  be  under  the  truth,  since  the  child 
would  only  know  of  such  marked  deficiency  of  health  as  would,  in  after  years, 
have  been  matter  of  frequent  conversation.  It  is  also  necessary  to  consider  the 
two  periods  together;  for  although  it  may  be  objected  that  the  condition  of  the 
health  of  the  parent,  after  the  birth  of  the  child,  in  no  way  concerned  the  health 
of  that  child,  there  is  strong  presumptive  evidence  that  general  feeble  health 
throughout  life  indicated  a  condition  of  the  constitution  below  that  of  health, 
and  hence  would  have  existed,  although  it  might  not  have  demonstrated  itself 
before  the  birth  of  the  child.  We  shall,  therefore,  more  nearly  approach  the 
truth  if  we  take  the  larger  percentage  to  represent  the  true  state  of  the  system, 
and  affirm  that  one-third  of  the  parents  had  feeble  general  health. 

"  The  mortality  of  the  parents  was  such,  that  one-half  of  one,  and  more  than 
one-fourth  of  both,  were  dead  at  the  period  of  the  inquiry.  Hence,  in  three- 
fourths  of  the  cases,  one  or  both  parents  had  died.  In  the  same  manner  it  is 
shown  that  in  only  one-fourth  of  the  cases  were  both  parents  living.  The  value 
of  these  facts  can  only  be  estimated  by  considering  the  age  of  the  child  at  the 
period  of  inquiry,  and  the  age  of  the  parent  at  the  period  of  death ;  for  it  is 
evident  that,  as  the  child  was  younger  or  older,  so  would  the  parents,  in  the 
natural  order  of  things,  be  living  or  dead.  The  average  age  of  the  patients,  at 
the  period  of  the  inquiry,  was  28.8  years.  The  age  of  the  parents  at  their  death, 
hs  ascertained  by  direct  inquiry,  was  such  that  one-half  of  them  died  between 
35  and  55  years  of  age — that  is  to  say,  in  middle' life;  but  still  a  larger  propor- 
tion died  after  than  before  the  period,  so  that  some  lived  to  upwards  of  90  years, 
and  more  than  one-third  of  the  whole  lived  to  above  the  period  when  the  majority 
died.  The  proportion  of  earlier  deaths  was  about  one-third  of  the  latter  number, 
and  was  therefore  inconsiderable. 

"The  influence  of  the  acquired  causes  of  disease  in  the  parents  has  not  been 
inquired  into  beyond  the  comprehensive  question  of  unsteadiness  of  life  ;  and  the 
frequent  occurrence  of  this  cause  has  considerable  importance.  Of  the  diseases 
which  had  occurred,  other  than  phthisis,  we  may  remark  that  only  rheumatism 
and  asthma  were  sufficiently  frequent  to  attract  attention ;  and  it  cannot  be 
presumed  that  they  had  any  very  direct  bearing  upon  the  general  health  of  the 
children.  Such  diseases  as  gout,  cancer,  and  various  kinds  of  fevers,  were  un- 
frequent ;  and,  with  the  exception  of  liver  disease,  the  others  were  not  worthy 
of  attention..  Hence,  we  do  not  think  that  these  diseases  of  the  parents  had 
either  an  indicative  or  causative  value  in  reference  to  production  of  phthisis  in 
the  child. 

"It  is  of  interest  to  remark  how  prolific  were  the  parents  of  phthisical  pa- 
tients, for  an  average  of  7|  children  to  each  family  is  much  greater  than  that  of 
the  general  community;  and  also  that,  in  so  large  a  proportion,  the  patient  was 
the  first  or  second  child. 

"  The  importance  of  the  first  fact,  therefore,  extends  chiefly  to  the  early  period 
of  life,  and  does  not  show  that  it  had  produced  a  feeble  state  of  the  vital  powers, 
such  as  might  have  been  inferred  if  the  patients  were  chiefly  the  last  children 
born.  Neither  are  we  entitled  to  affirm  that  the  powers  of  the  parents  were 
immature  when  the  patients  were  born ;  for  the  age  of  the  parents,  at  the  birth 
of  these  children,  shows  that  they  were  not  largely  the  product  of  very  early 
marriages,  but  they  were  born  at  a  period  of  life  when,  in  this  country,  the  body 
is  presumed  to  have  approached  maturity.  It  is  true  that  we  have  shown  that 
a  large  proportion  of  the  parents  had  feeble  general  health,  and  therefore  it 
might  occur  that  their  period  of  maturity  had  been  deferred  beyond  the  ordinary 
perid ;  but  if  debility  of  system  of  the  parent  be  presumed  to  be  a  predisposing 
cause  of  phthisis  in  the  child,  and  that  debility  had  existed  throughout  life,  it 
would  be  more  probable  that  its  effect  would  increase  as  life  advanced,  and  be 
more  evident  in  the  children  of  later  years. 

"  Hence,  whilst  these  facts  have  great  interest,  I  do  not  think  that  they  help 
us  to  any  affirmative  views  of  the  hereditary  nature  of  phthisis. 

"  The  mortality  of  the  children  was  considerable ;  since,  when  the  average 
age  of  the  parents  was  28  years,  40  per  cent,  of  the  children  had  died,  and  that 
fact  would  imply  the  existence  of  a  feeble  state  of  the  system. 

"  We  may  now  turn  to  the  other  aspect  of  the  question,  and  show  how  far  a 


484 


Progress  of  the  Medical  Sciences. 


[April 


direct  transmission  of  disease  might  have  occurred  in  the  cases  in  question.  It  is 
evident  that  the  solution  of  this  question  must  rest  alone  upon  the  occurrence  of 
phthisis  in  the  parents,  since  from  them  alone  could  the  disease  have  been 
transmitted.  To  introduce  the  occurrence  of  the  disease  in  the  next  relatives, 
viz.,  the  brothers  and  sisters,  would  be  valueless  and  superfluous ;  for,  if  the 
proposition  were  thus— because  the  brothers  and  sisters  of  the  patient,  as  well 
as  the  patient,  had  phthisis,  there  is  a  presumption  that  they  had  derived  it  in 
common  from  their  parents,  it  would  prove  nothing-  beyond  what  could  be  de- 
rived from  the  parents  alone,  by  ascertaining  their  mortality  from  phthisis,  unless 
we  are  at  liberty  to  infer  that  phthisis  is  a  disease  which  may  be  communicated 
through  the  parent  to  the  child,  without  the  parent  having  suffered  from  it — an 
inference  which,  although  supported  by  a  few  facts,  has  hitherto  found  no  place 
in  the  idea  of  the  hereditary  transmission  of  the  disease.  So,  in  like  manner,  we 
may  discard  inquiries  into  the  occurrence  of  phthisis  in  the  uncles,  aunts,  and 
cousins,  since  we  have  direct  testimony  as  to  the  parents  themselves. 

"In  only  one-fifth  of  the  cases  has  either  of  the  parents  died  of  phthisis, 
although  they  had  all  lived  until  middle  life ;  and  hence  we  may  support  the 
statement  of  Professor  Walshe,  derived  from  fewer  facts,  that  "  phthisis,  in  the 
adult  hospital  population  of  this  country,  is,  to  a  slight  amount  only,  a  disease 
demonstrably  derived  from  the  parents."  The  proportion  of  deaths  from  phthisis 
in  these  1000  cases  was,  however,  somewhat  higher  than  that  which  is  found  in 
the  community  as  a  whole. 

"As  a  general  result  of  the  inquiry  under  this  head,  we  may  affirm  that  phthisis 
is  not  necessarily  nor  usually  a  disease  directly  transmitted  from  the  parent  to 
the  offspring,  but  that  in  a  large  proportion  of  phthisical  patients  the  parents 
and  brothers  and  sisters  had  experienced  feeble  health,  and  a  somewhat  lessened 
duration  of  life.    There  was  not,  however,  a  majority  of  the  cases  so  connected. 

"The  next  question  of  interest  is  the  liability  of  females  over  males  to  many 
of  the  conditions  which  have  been  embraced  by  this  inquiry.  There  is  a  singular 
unanimity  in  this  respect  with  regard  to  the  most  important  subjects.  Thus, 
in  reference  to  the  parents,  more  mothers  than  fathers  had  children  early,  had 
feeble  general  health  both  before  and  after  the  birth  of  the  patient,  and  had 
died  early.  Of  the  patients,  more  females  than  males  had  mothers  who  died 
early;  had  most  parents,  brothers,  sisters,  and  other  relatives  who  had  died  of 
phthisis;  had  parents  with  one  child  only;  had  experienced  feeble  health  and 
defective  appetite  throughout  life ;  had  been  believed  to  have  delicacy  of  the 
lungs ;  were  young  when  their  first  child  was  born ;  had  children  of  feeble 
health  :  and  had  lost  most  children.  Of  the  less  important  questions  it  may  be 
added,  that  more  females  than  males  had  suffered  from  anxiety ;  had  had  measles, 
scarlatina,  and  hooping  cough  ;  had  not  worn  flannel  upon  the  skin  ;  had  a  very 
defective  education  ;  were  of  a  susceptible  temperament ;  had  brown  eyes,  florid 
complexion,  and  fleshy  habit;  and  had  experienced  coldness  of  the  extremities. 
Such  a  preponderance  of  evils  in  one  sex  is  most  striking,  and  is  not  paralleled 
by  any  observation  hitherto  recorded.  It  also  shows  how  great  is  the  mother's 
influence  upon  the  health  of  the  children,  and  how  much  greater  watchfulness 
should  be  exercised  over  the  female  part  of  the  population. 

"3d.  Of  the  group  of  questions  which  have  a  direct  bearing  upon  the  health 
of  the  patients,  it  may  be  remarked: — 

"1.  That  debility  of  the  general  system,  both  at  birth  and  in  later  life,  was 
not  a  marked  feature,  since  two-thirds  had  enjoyed  good  health  and  appetite 
through  life ;  but  the  remaining  proportion  of  one-fourth  had  been  feeble  from 
birth.  Of  the  periods  during  growth,  that  from  set.  14  to  21  had  a  preponder- 
ance of  cases  in  feeble  health,  but  only  to  a  moderate  degree.  Known  delicacy 
of  the  lungs  was  found  in  only  one-twelfth  of  the  cases;  coldness  of  the  extremi- 
ties was  experienced  in  one-half  of  the  cases  ;  and  there  was  a  well-marked  ten- 
dency to  free  perspiration.    Leucorrhcea  was  prevalent. 

"2.  The  menses  did  not  appear  too  early  on  the  average,  neither  were  they 
in  excess  either  in  time  or  quantity.  Early  marriages  were  not  common,  but 
the  health  of  the  children  was  bad  and  the  mortality  great  in  one-half  the  cases. 
Abortions  were  frequent,  and  the  patients  were  prolific  beyond  that  of  the 
general  community.    Sterility  was  found  in  one-eighth  of  the  married  cases. 


1863.] 


Medical  Pathology  and  Therapeutics. 


485 


"3.  Immorality  of  life  in  the  males,  for  a  limited  period,  was  frequent.  Sy- 
philis and  gonorrhoea  had  occurred  and  recurred  frequently.  Masturbation  and 
seminal  emissions  had  been  common.  The  evils  attending  occupation  were  very 
considerable  and  important,  since  in  two-thirds  of  the  cases  they  were  complained 
of.  Of  these,  long  and  late  hours,  close  and  hot  rooms,  and  exposure,  were  the 
most  frequent.    Anxiety  was  prevalent. 

"4.  Of  the  sporadic  disease  of  infancy,  by  far  the  most  frequent  was  measles; 
and  neither  scarlatina  nor  smallpox  had  occurred  in  one-half  of  the  cases.  The 
occurrence  of  each  of  the  diseases  in  adult  life  was  recorded,  but  it  was  very 
unfrequent.    Evils  resulting  from  these  diseases  were  very  insignificant. 

"  5.  The  occurrence  of  the  evidence  of  scrofulous  disease  was  very  rare,  except 
in  the  instance  of  enlarged  glands  ;  but  it  is  possible  that  a  different  result  might 
be  obtained  from  inquiries  made  at  the  children's  hospital  and  in  institutions 
w^ere  scrofulous  cases  are  congregated.  At  the  Hospital  for  Consumption 
there  is  shown  to  be  no  general  or  necessary  connection  whatever  between 
marked  scrofulous  diseases  and  phthisis. 

"6.  Of  general  diseases,  those  only  which  were  frequent  were  inflammation  of 
the  lungs  and  rheumatism. 

"7.  The  occurrence  of  consanguinity  in  the  parents,  and  of  dry-nursing  was 
scarcely  found.  Asthma  was  found  in  one  of  the  parents,  and  chiefly  the  mother, 
somewhat  frequently. 

■  "I  have  not,  in  this  summary,  entered  into  a  minute  analysis  of  the  results 
obtained  in  this  inquiry,  but  have  selected  only  those  which  occupy  a  prominent 
place,  or  may  be  grouped  together.  The  results  obtained  will  bear,  it  is  hoped, 
an  importance  beyond  that  to  which  I  have  applied  them,  and  will  be  of  greater 
value  when  similar  inquiries  shall  have  been  made  upon  other  large  sections  of 
the  community.  Whilst  it  has  been  shown  that  many  conditions  have  less  im- 
portance in  connection  with  phthisis  than  has  heretofore  been  believed,  there  is 
much  evidence  to  show  that  the  disease  is  frequently  allied  with  a  state  of  system 
defective  in  vital  power  and  resistance,  both  of  the  patient,  and  his  parents,  and 
his  children.  The  large  proportion  in  which  none  of  those  states  of  health  could 
be  discovered,  is,  however,  sound  proof  that  phthisical  patients  are  a  mixed 
class,  and  that  the  disease  arises  under  very  diverse  conditions.  As  to  the  bear- 
ing of  this  inquiry  upon  life  assurance,  I  think  it  may  be  inferred  that  there  is 
no  such  oneness  of  type  of  constitution  that  the  most  minute  historical  research 
could  be  a  sufficient  guide  as  to  the  future  probability  of  the  occurrence  of  con- 
sumption. There  is  clearly  great  diversity  of  causes  leading  to  that  issue,  and 
hereditary  influence  can  only  be  regarded  as  one  of  them.  If  the  inquiry  could 
have  determined  the  proportion  of  persons  derived  from  consumptive  parents 
who  would  themselves  become  consumptive,  it  would  have  been  more  to  this 
purpose  ;  but  such  an  inquiry  is  manifestly  impossible.  The  only  safeguard  to 
life  offices  is,  I  believe,  the  estimation,  by  careful  examination,  of  the  degree  of 
health  of  the  proposed  assurer ;  and,  above  all,  the  careful  examination  of  the 
chest  by  those  whose  duties  make  them  especially  familiar  with  the  subject,  and 
particularly  with  the  early  conditions  which  precede  the  ordinary  manifestations 
of  lung  disease." 

22.  Cases  of  Phthisis — Arrest  of  the  Disease,  and  remarkable  gain  in 
Weight. — Case  1.  M.  N.,  aged  17,  a  servant,  residing  at  Stepney,  admitted  to 
Montgomery  Ward  [Hospital  for  Consumption  and  Diseases  of  the  Chest, 
Brompton],  Aug.  25,  1862,  under  Dr.  Pollock.  Father  died  of  phthisis.  Ill 
two  years,  cough  constant,  but  very  moderate  expectoration.  Never  had 
haemoptysis  ;  has  lost  much  flesh ;  night  sweats  last  three  months.  Complains 
of  pain  in  right  side  and  back,  much  debility,  dyspnoea,  vertigo,  tinnitus  aurium, 
and  dim  vision.  Pulse  rapid,  small ;  tongue  clean  ;  appetite  good  ;  catamenia 
had  appeared  once  only,  six  months  ago. 

Physical  Signs. — Right :  dulness  from  the  clavicle  to  the  third  rib  ;  blowing 
on  inspiration  and  expiration,  and  large  dry  crackle.  Some  signs  in  supra- 
spinous fossa.  Base  clear.  Left :  expiration  much  prolonged,  and  rough  respira- 
tion throughout. 

The  girl  stated  that  she  had  lived  well,  had  had  meat  daily,  and  had  not  been 


486  Progress  of  the  Medical  Sciences.  [April 


The  following  is 

her  weight  table 

St. 

lbs. 

The  progressive  increase  has  been : 

Sept.  1 
"  15 

.  7 

Q* 

.  7 

7 

1st  fortnight  gained 
2d        "  . 

"  29 

.  7 

10 

Oct.  13 

.  8 

oi 

3d      "       "       .  .  , 

"  27 

.  8 

5 

4th       "          "  . 

Nov.  10 

.  8 

7 

5th       "          "         .       .  . 

Dec.  1 

.  8 

13 

Last  three  weeks 

overworked.  She  was  ordered  a  dessertspoonful  of  cod-liver  oil  twice  daily,  and 
five  grains  of  citrate  of  iron  in  infusion  of  calumbo.  The  latter  was  changed  a 
month  later  for  a  mixture  of  citrate  of  iron  and  quinine.  Full  diet  consisting  of 
four  liberal  meals  per  diem,  one  of  them  of  meat  ad  libitum,  and  wine. 


lbs. 
3 

2^ 
6 


Total  gain  in  91  days  .  .27 

Cod-liver  oil  had  been  regularly  taken  for  three  months  before  admission. 

On  November  12,  the  following  were  the  physical  signs  on  the  right  side : 
Dulness,  as  before ;  dry,  leathery,  creaking  sounds  have  replaced  the  cracking 
under  the  clavicle;  below  this  is  heard  a  whiffing,  dry  inspiration;  no  moist 
sounds  anywhere ;  the  catamenia  are  still  absent.  This  patient  expresses  her- 
self as  much  relieved,  and  seems  not  to  have  much  the  matter  with  her.  The 
night  sweats  ceased  long  ago. 

Remarks  by  Dr.  Pollock. — This  seems  to  be  a  case  of  chronic  tubercle  in  one. 
lung,  derived  hereditarily,  with  little  activity  of  the  constitutional  mischief,  and 
arrested  before  softening  had  occurred  to  any  extent,  and  before  the  isolated 
deposits  had  coalesced  to  form  a  cavity.  On  the  eve,  as  it  were,  of  such  occur- 
rence, the  disease  stopped  short,  the  tubercle  tending  to  dry,  local  irritation 
ceasing,  and  the  nutritious  processes  of  the  body  proceeding  rapidly  to  replace 
the  waste  undergone  by  the  tissues.  It  is  important  to  observe  that  this  patient 
was  not  taken  from  poverty  and  placed  in  the  midst  of  plenty,  for  her  living  had 
been  previously  good ;  but  it  is  equally  important  to  remember  that  she  was 
taken  from  a  life  of  daily  labour  and  anxiety,  and  placed  where  there  was  no 
necessity  of  any  exertion  of  mind  or  body,  and  where  every  want  was  cared  for. 
The  remedial  influences  were,  therefore,  many  in  addition  to  those  purely  medi- 
cinal.   She  had  taken  cod-liver  oil  for  three  months  before  admission. 

The  following  case  presents  many  points  of  similarity: — ■ 

Case  2.  M.  A.  G-.,  aged  15,  tailoress,  admitted  under  Dr.  Pollock,  August  26, 
1862,  Harewood  ward.  Has  always  lived  at  home ;  the  family  being  in  com- 
fortable circumstances,  had  meat  daily.  Of  middle  height,  chest  pretty  well 
shaped,  hair  light  brown  ;  of  lymphatic  temperament.  Her  father,  mother,  and 
several  maternal  uncles  and  aunts,  died  of  phthisis.  Ill  three  months,  cough 
constant  for  that  period,  with  slight  expectoration.  No  haemoptysis;  catamenia 
established  at  13,  now  absent  for  five  months  ;  no  sweatings  ;  complains  of  cough, 
debility,  flushing ;  appetite  indifferent ;  tongue  clean  ;  pulse  quiet. 

Physical  Signs. — Left:  dulness  on  percussion  ;  humid  crepitus  over  the  whole 
front  and  axilla ;  also  in  supra-spinous  fossa ;  rough  respiration  at  base  poste- 
riorly. Right :  percussion  slightly  dull ;  clicking  sounds  in  supra-spinous  fossa, 
and  along  spine ;  posterior  base  pretty  clear.    She  has  considerably  lost  flesh. 


The  following  is  her  weight  tabic  : — 


St. 

lbs. 

Sept.  1 
"  15 

.       .  6 

13 

.  7 

4 

1st  fortnight  gained 

"29 

.  7 

8 

2d 

Oct.  13 

.  7 

13 

3d 

"27 

1 

4th 

Nov.  10 

.  8 

6 

5th 

"24 

.  8 

H 

6th 

The  progressive  increase  has  been  :- 


Total  gain  in  85  days  . 


lbs. 

5 
4 
5 
2 

5 

H 
22£ 


1863.]  Medical  Pathology  and  Therapeutics.  487 

This  girl  is  also  now  in  a  very  comfortable  condition,  coughs  little,  sleeps 
well,  and  expectorates  scarcely  anything.  The  catamenia  have  not  been  re- 
established. 

The  physical  signs  in  this  case  underwent  an  alteration  coincident  with  the 
improvement  in  health.  On  November  12,  a  careful  examination  gave  rough, 
dry  inspiration,  and  prolonged  expiration  over  left  side,  instead  of  the  humid 
crepitus  formerly  noticed. 

The  points  of  resemblance  in  the  two  cases  (Dr.  Pollock  said)  were  :  In  both 
the  disease  was  hereditary ;  occurred  at  the  period  of  growth  ;  in  neither  had 
there  been  haemoptysis ;  the  absence  of  fever,  and  the  similarity  of  tempera- 
ment (the  lymphatic);  the  moderate  amount  of  expectoration;  the  unimpaired 
condition  of  the  digestive  functions;  the  suspension  of  uterine  activity;  the 
limited  amount  of  disease  in  the  lung;  and  the  characters  of,  and  changes  in, 
the  physical  signs  denoting  a  deposit  in  the  lung  undergoing  alterations  rather 
of  an  absorptive  than  of  a  softening  nature.  A  theoretical  view  of  the  two  cases 
implies  that  a  slight  injury  having  been  sustained  by  the  lung,  not  only  did  the 
deposit  undergo  changes  indicating  a  tendency  to  dry  up,  and  leave  behind 
merely  the  inorganic  elements  of  tubercle,  but  the  still  more  important  fact, 
that  the  impairment  of  nutrition,  in  which  the  morbid  changes  originated,  had 
ceased,  and  that  the  tissues  of  the  body  were  again  being  built  up  of  healthy 
material.  Such  a  condition  may  fairly  be  called  an  "arrest"  of  diseased  action, 
and  exhibits,  hopefully  to  the  practitioner,  clear  evidence  of  the  reparative 
powers  and  tendencies  of  the  system. — Med.  Times  and  Gaz.,  Jan.  24,  1863. 

23.  Clubbed  Fingers  in  Diseases  of  the  Chest. — M.  Trousseau  carefully  points 
out  every  year  to  his  pupils  the  peculiar  deformation  of  the  hand,  called  hippo- 
cratic  or  clubbed  finger,  which,  since  the  most  remote  antiquity,  has  attracted 
the  notice  of  pathologists.  Ancient  writers  thus  describe  the  appearance  of 
the  Imagers  in  consumptive  subjects:  "  Tabidis  ungues  contrahuntur,  or  "tahi- 
dis  ungues  adunci."  In  1832,  M.  Pigeaux,  a  Paris  practitioner,  again  invited 
attention  to  this,  in  some  measure,  forgotten  symptom,  and  endeavoured  to 
•  establish  with  precision  its  semeiotic  value.  M.  Trousseau  describes  it  as  fol- 
lows :  It  is  a  shortening  of  the  third  or  ungual  phalanx,  attended  with  inspissa- 
tion  and  transversal  enlargement  of  the  digital  extremity.  The  nail,  at  the 
same  time,  becomes  incurvated  and  the  point  of  the  finger  assumes  the  shape 
of  a  club,  or  more  properly,  of  the  head  of  a  serpent.  The  deformation  is  some- 
times a  slow  process,  but  occasionally  takes  place  very  rapidly,  and  not  without 
pain.  M.  Trousseau  remarks  that,  not  having  observed  clubbed  fingers  in 
genuine  scrofula,  nor  in  uncomplicated  abdominal  tuberculosis,  he  inclines  to 
consider  the  symptom  as  special  to  chronic  affections  of*the  chest.  He  has  met 
with  it  in  the  second  and  third  stages  of  pulmonary  consumption,  and  in  young 
subjects  suffering  from  chronic  pleurisy.  The  sign  is  not,  therefore,  exclusively 
pathognomonic  of  phthisis ;  but  the  clubbed  finger  is  much  more  frequently 
observed  during  the  progress  of  that  affection,  and  the  unciform  nail  becomes 
better  marked  in  proportion  as  the  disease  is  in  a  more  advanced  stage.  In 
the  main,  M.  Trousseau  opines  that  the  hippocratic  finger  affords  valuable  pre- 
sumptive evidence  of  the  existence  of  pulmonary  consumption.  He  ascribes 
the  alteration  of  shape  to  hypertrophy  of  the  bone,  or  at  least  to  preternatural 
development  of  the  fibro-cellular  tissue  in  the  pulp  of  the  finger,  invading  the 
thumb  and  index,  first  of  the  right  and  afterwards  of  the  left  hand  ;  the  other 
fingers  becoming  successively  affected  in  the  order  of  their  development,  the 
little  finger  thus  preserving  sometimes  its  natural  form,  while  all  the  others  are 
already  distinctly  clubbed.  M.  Caron  recently  brought  the  question  before 
one  of  the  medical  societies  of  Paris ;  and  although  he  agrees  with  MM.  Pi- 
geaux and  Trousseau  as  to  the  semeiotic  import  of  the  symptom,  he  connects  it 
also  with  the  scrofulous  diathesis.  In  a  recent  number  of  the  Revue  Me'dicale. 
a  new  explanation  of  the  deformation  of  the  fingers  is  given  by  M.  de  Saint- 
Maclout.  He  observes,  that  in  cyanosis,  as  M.  Gintrac  has  before  correctly 
remarked,  the  digital  extremities  sometimes  assume  the  hippocratic  character. 
The  disturbance  of  nutrition  in  the  cyanosis  is  consequent  on  the  admixture  of 
venous  with  arterial  blood ;  and  it  does  not  appear  improbable  that  the  same 


488 


Progress  of  the  Medical  Sciences. 


[April 


morbid  confusion  of  the  two  kinds  of  blood  also  induces  the  clubbed  form  of  the 
tips  of  the  fingers  in  phthisis.  M.  de  Saint-Maclout  adduces  in  support  of  his 
opinion  M.  Natalis  G-uillout's  researches  on  the  disarterialization  of  the  blood 
which  passes  through  the  lungs  in  tuberculosis. — British  Med.  Journal,  Dec. 
13,  1862,  from  Jour,  de  Mid.  et  de  Ckir.  Prat. 

24.  Generalized  Emphysema. — Under  this  name  Mr.  Henri  Roger,  in  a 
memoir  read  before  the  Academy  of  Medicine  in  Paris,  has  described  a  rare 
form  of  disease,  occurring  generally  in  children.  In  the  course  of  an  acute  in- 
flammation of  the  respiratory  organs,  there  is  suddenly  developed,  at  the  side 
of  the  neck,  a  soft  tumour  with  characteristic  crepitation  ;  the  tumour  is  at  first 
circumscribed,  but  soon  extends  in  all  directions  through  the  subcutaneous 
areolar  tissue.  In  such  cases,  M.  Roger  says,  the  emphysema  has  commenced 
in  the  lung,  has  traversed  the  areolar  tissue  of  the  mediastinum,  and  finally  has 
reached  the  subcutaneous  tissue.  This  condition,  hitherto  scarcely  recognized, 
has  been  noted  by  M.  Roger  in  nineteen  cases,  of  which  ten  were  observed  and 
published  by  him  and  M.  Blache,  and  nine  have  been  collected  by  him  from 
various  sources. 

Generalized  emphysema  occurs  exceptionally  in  old  age,  very  rarely  in  adults, 
but  with  comparatively  great  frequency  in  young  children  :  fifteen  of  the  cases 
were  in  children  under  four  years  of  age.  In  nearly  one-half  of  the  cases,  it  was 
preceded  by  hooping-cough. 

In  generalized  emphysema,  there  is  no  spontaneous  production  of  gas  by 
morbid  fermentation,  as  happens  in  certain  gangrenous  affections.  The  air 
comes  from  the  respiratory  organs,  by  rupture  of  the  air-tubes  or  laceration  of 
the  parenchyma  of  the  lungs.  On  post-mortem  examination,  emphysema  of  all 
varieties — vesicular,  interlocular,  and  interlobular — is  found  in  the  lungs ;  the 
mediastina  are  found  riddled  with  vesicles  and  bubbles  of  air :  and  at  the  same 
time  air  is  found  in  the  subcutaneous  areolar  tissues.  The  emphysema  of 
the  mediastina  arises  either  from  the  direct  passage  of  the  respiratory  air 
through  the  laryngo-tracheal  tube,  or  from  the  extension  of  the  pulmonary 
emphysema.  When  a  lung  is  highly  emphysematous  both  in  its  interior  and  at 
its  surface  near  the  exit,  emphysema  of  the  mediastina  may  arise  in  two  ways. 
1.  The  subpleural  mass  of  air,  pushed  on  by  fresh  supplies  which  have  escaped 
during  forcible  attempts  at  respiration,  raises  the  pleura  without  rupturing  it, 
and  reaches  the  point  of  reflection  of  this  membrane ;  having  arrived  here,  it 
passes  into  the  cellular  tissue  of  the  mediastinum.  2.  A  deeply  seated  distended 
vesicle  ruptures,  and  the  air  passes  along  the  cellular  sheath  of  the  bronchi  and 
pulmonary  vessels  to  the  root  of  the  lung,  where  it  enters  the  mediastinum. 
This  migration  of  the  aif  from  the  lung  to  the  mediastinum,  and  from  the  medi- 
astinum to  th'e  external  areolar  tissue  takes  place  during  the  paroxysms  of 
suffocative  dyspnoea  which  attend  double  pneumonia,  or  during  the  convulsive 
paroxysms  of  hooping-cough :  the  air,  compressed  by  the  violent  respiratory 
efforts  between  the  termination  of  the  air-passages  and  the  closed  glottis,  breaks 
through  the  least  resisting  parts — those  parts  of  the  pulmonary  parenchyma 
which  have  undergone  structural  change  in  consequence  of  the  primary  disease. 

Generalized  emphysema,  when  it  occurs,  usually  appears  suddenly,  at  the 
acme  of  some  acute  affection  of  the  air-passages,  without  any  peculiar  premoni- 
tory or  concomitant  symptoms.  The  first  symptom  is  a  tumour  at  the  base  of 
the  neck,  under  the  jaw,  and  even  extending  on  the  cheek :  it  is  soft,  and  yields 
to  the  finger  and  ear  a  pathognomonic  crepitation,  which  is  sometimes  increased 
by  coughing  or  crying.  In  a  few  hours,  the  emphysema  spreads  in  all  direc- 
tions, making  the  patients  appear  as  if  they  were  anasarcous;  the  general  symp- 
toms are,  as  a  rule,  aggravated  at  the  same  time. 

This  form  of  emphysema  is  generally  fatal :  death  occurred  in  fifteen  cases  out 
of  the  nineteen.  Death  occurs  in  one  or  two  days,  sometimes  even  in  a  few  hours 
or  minutes;  it  is  rarely  delayed  several  days.  But  the  unfavourable  prognosis 
depends  less  on  the  emphysema  than  on  the  severity  of  the  disease  which  has 
given  rise  to  it. 

In  the  treatment,  the  first  indication  is  to  calm  the  violent  respiratory  efforts 
which  give  rise  to  the  emphysema ;  and  this  is  to  be  fulfilled  by  the  use  of  full 


1863.] 


.  Medical  Pathology  and  Therapeutics. 


489 


doses  of  digitalis,  with  opium.  The  absorption  of  the  infiltrated  air  must 
depend  on  the  natural  powers  of  the  system  ;  but  it  may,  perhaps,  be  hastened 
by  stimulant  frictions  over  the  affected  parts ;  and,  in  cases  where  the  external 
emphysema  is  very  severe  and  oppressive,  an  exit  may  be  given  to  the  air  by 
punctures  made  with  a  capillary  trocar. — British  Med.  Journal,  June  7,  1863, 
from  Rtvue  de  Th6r.  Mtd.-Chir.,  1  Avril,  1862. 

25.  Enormous  Spleen. — Mr.  Nunn  showed  to  the  Pathological  Society  of 
London,  Dec.  2,  1862,  a  section  of  a  spleen,  which  weighed  thirteen  and  a  half 
pounds.  Its  transverse  circumference  was  thirteen  and  a  half  inches ;  its  longi- 
tudinal, thirty-two.  It  occupied  one-half  the  cavity  of  the  abdomen.  The 
patient  died  of  exhaustion  and  peritonitis.  There  was  also  a  large  quantity  of 
fluid  in  the  abdominal  cavity. 

Dr.  Murchison  asked  if  the  blood  had  been  examined. 

Mr.  Spencer  Wells  said  that,  more  than  twenty  years  ago,  Dr.  Eobert  Wil- 
liams had  made  known  the  remarkable  power  exercised  by  bromide  of  potas- 
sium in  reducing  enlargements  of  the  spleen,  and  had  led  to  the  admission  of 
this  remedy  to  the  Pharmacopoeia.  He  (Mr.  Wells)  had  seen  some  extraordi- 
nary instances  of  this  power,  in  cases  of  enlarged  spleen  following  the  fevers  of 
the  Mediterranean.  In  more  than  one  case,  the  process  of  diminution  was  dis- 
tinctly traced  inch  by  inch,  and  a  spleen  which  had  reached  the  pubis  and  right 
ilium,  had  returned  to  a  very  small  size  under  the  use  of  eight  grains  of  the 
bromide  given  three  times  a  day.  He  would,  therefore,  like  to  know  if  this 
remedy  had  been  tried  by  Mr.  Nunn;  and  if  so,  and  it  had  proved  useless, 
whether  (as  the  patient  was  apparently  being  killed  by  the  splenic  tumour,  and 
by  nothing  else)  the  question  of  removal  by  surgical  operation  had  been  con- 
sidered. The  spleen  could  be  removed  very  easily  in  dogs  and  other  animals ; 
they  seemed  to  remain  perfectly  well  without  a  spleen,  and  there  certainly  could 
not  be  more  difficulty  in  removing  a  large  spleen  from  the  human  body  than  a 
large  ovarian  tumour.  For  his  own  part,  if  he  met  with  a  case  where  a  patient 
was  evidently  being  killed  by  a  large  spleen,  where  all  remedies  had  proved  use- 
less, and  where  the  dying  person  was  willing  to  run  the  risk  on  the  chance  of 
saving  his  life,  he  would  certainly  be  disposed  to  remove  the  tumour. 
»  Dr.  Murchison  thought  there  would  be  more  difficulty  in  securing  the  splenic 
vessels  than  was  met  with  in  securing  the  vessels  of  an  ovarian  tumour. 

Dr.  Wilks  said  Mr.  Wells'  suggestion  might  prove  a  very  valuable  one. 
People,  undoubtedly,  did  die  of  enlarged  spleens,  who  had  no  other  disease. 
The  bromide  of  potassium  was  only  useful  in  those  forms  of  enlarged  spleen 
which  followed  intermittent  fevers.  In  the  simple  hypertrophy  of  the  spleen, 
of  which  he  believed  Mr.  Nunn's  specimen  to  be  an  example,  and  in  the  larda- 
ceous  form  of  disease,  the  bromide  was  equally  useless.  In  those  cases  it  was 
very  well  worth  while  to  consider  whether  a  surgical  operation  might  not  save 
life. 

Dr.  Gibb  had  once  removed  an  enlarged  spleen  from  a  dog.  The  animal 
lived  six  days,  and  then  died  of  peritonitis. 

Mr.  Nunn  said  that  the  blood  had  not  been  examined. — Med.  Times  and 
Gaz.,  Dec.  13,  1862. 

26.  Disease  of  the  Supra-renal  Capsules  without  Bronzing  of  the  Skin. — It  is 
supposed  by  some,  that  disease  of  the  supra-renal  capsules  alone  is  not  the 
cause  of  the  symptoms  of  Addison's  disease,  but  that  it  is  disease  spreading 
from  them  to  the  contiguous  semilunar  ganglia  and  solar  plexus.  But,  in  the 
following  case,  "the  semilunar  ganglia  were  more  than  usually  involved.  The 
right  one  was  actually  imbedded  in  the  capsule."  Here,  then,  is  a  well-marked 
case  of  disease  of  the  capsules,  affecting  also  the  great  ganglial  centres  in  the 
abdomen,  and  yet  the  most  marked  symptom  is  wanting.  This  case  will,  doubt- 
less, be  cited  by  those  who  do  not  believe  in  Dr.  Addison's  views,  as  an  instance 
contradictory  to  his  theory.  But  although  the  discoloration  of  the  skin  is  the 
most  marked  symptom,  it  has  never  been  considered  the  most  characteristic. 
Dr.  Wilks  says,  in  a  paper  in  the  last  number  of  Guy's  Hospital  Reports,  "the 
discoloration  of  the  skin,  although  a  striking  feature  of  the  complaint,  was  not 


490  Progress  of  the  Medical  Sciences.  *  [April 


the  main  one  insisted  on  by  Addison ;  but  since  it  is  that  which  can  be  por- 
trayed in  a  drawing,  and,  consequently,  apt  to  strike  the  eye  on  turning  over 
the  pages  of  a  monograph,  it  is  not  surprising  that  it  was  at  once  regarded  as  the 
most  remarkable  part  of  the  complaint,  and  would,  therefore,  be  especially  dwelt 
upon  in  our  ordinary  mode  of  communicating  to  one  another  the  facts  relating 
to  the  disease,  until,  at  last,  the  erroneous  opinion  would  be  reached  that  Addi- 
son's disease  and  discoloration  of  the  skin  were  convertible  terms.  In  the  same 
article,  Dr.  Wilks  relates  a  case  (Case  8  of  his  series)  in  which  there  was  disease 
of  the  capsules,  and  no  change  of  colour  of  the  skin.  Yet  a  most  characteristic 
symptom,  "an  utter  prostration  of  strength,"  was  not  absent. 

Dr.  Harley  considers  that  disease  of  the  supra- renal  capsules  is  not  fatal ;  but, 
he  says,  disease  may  extend  from  them  to  the  semilunar  ganglia  or  solar  plexus, 
or  may  excite  such  an  amount  of  irritation  in  them  as  to  induce  secondary 
disease,  which,  and  not  the  contemporaneous  affection  of  the  capsules,  may  cause 
death.  He  states  that  a  rat,  from  which  he  had  removed  both  capsules,  lived 
in  good  health  three  years  after  the  operation,  and  died  at  the  end  of  that  time 
of  old  age.  He  says,  that  in  all  cases  in  which  the  animals  have  died  after 
removal,  it  is  clearly  due  to  the  effect  of  the  operation,  and  not  to  the  loss  of 
the  capsules.  The  fact  that  rats,  in  which  the  capsules  are  loose  and  easily 
removed,  generally  recover,  whilst  guinea-pigs  and  rabbits,  in  which  they  are 
intricately  involved  in  the  abdominal  plexus,  frequently  die,  tends  to  favour  the 
idea,  that  death  is  due  to  the  operation  alone. 

In  the  article  already  referred  to,  Dr.  Wilks  writes,  "  the  symptoms  cannot 
be  due  simply  to  a  destruction  of  the  organs,  since  this  must  have  happened, 
in  many  instances,  long  before  death  occurred,  and  is  one  reason,  as  before  said, 
to  suggest  some  implication  of  the  organic  system  of  nerves."  In  the  case  we 
are  about  to  relate,  as  in  case  8  of  Dr.  Wilks'  series,  before  alluded  to,  the  dis- 
ease was  in  an  early  stage.  Dr.  Wilks  says  (op.  cit.,  p.  13):  "A  sufficient 
number  of  cases  have  now  been  observed  to  suggest  whether  the  change  in  the 
skin  does  not  depend  on  the  chronicity  of  the  disease ;  and  that,  if  it  should 
progress  rapidly,  no  discoloration  of  the  skin  would  be  observed,  the  symptoms 
being  merely  those  of  asthenia." 

William  T.,  a  publican,  aged  31,  was  first  seen  at  home  by  Dr.  Gull  on  Decem- 
ber 26.  The  case  being  a  very  obscure  one,  the  patient  was  sent  to  the  hospital,  « 
and  admitted  on  December  27.  He  died  on  the  29th,  before  he  had  been  seen 
a  second  time  by  Dr.  Gull.  As  far  as  could  be  learned  he  had  been  ailing 
about  four  months,  or,  at  least,  there  was  no  symptom  to  attract  attention 
before  that.  He  then  began  to  get  weak,  pale,  and  thin.  A  medical  man  was 
called  in,  who  gave  him  medicines  with  varying  effect;  and  it  was  his  opinion 
that  he  was  consumptive.  At  this  time  he  often  had  sickness,  his  appetite  was 
b^d,  and  he  also  at  times  complained  of  pain  in  his  back.  He  had  also  various 
nervous  symptoms,  which  were  differently  described ;  it  being  stated  that  he 
had  lost  sensation  on  one  side  of  his  face,  and  could  not  eat  so  well  on  that  side ; 
and  that  he  had  numbness  in  his  legs,  and  that  he  could  not  hold  his  water  per- 
fectly. He  still  continued  at  his  employment.  About  a  month  before  his  death 
he  became  much  worse,  with  all  the  above-named  symptoms,  and  he  then  went 
to  Greenwich  for  change  of  air.  He  still  became  worse,  however,  the  pain  in 
his  back  becoming  more  severe.  He  returned  home,  but  was  obliged  to  ride 
from  the  railway  station  to  his  house,  a  short  distance.  On  December  26,  Dr. 
Gull  was  requested  to  see  him,  and  advised  his  removal  to  the  hospital.  He 
was  admitted  the  next  day,  December  27.  He  was  so  weak  that  it  was  neces- 
sary to  c  arry  him  to  the  ward.  He  then  brought  up  all  the  food  he  took,  but 
rallied  somewhat  the  next  day.  The  next  day  Mr.  Stocker  saw  him.  and  found 
him  dying,  after  having  vomited.  Mr.  Stocker  said,  that  from  this,  his  only 
visit  to  the  patient,  he  did  not  know  whether  he  was  suffering  from  stomach, 
cerebral,  or  supra-renal  disease. 

The  man's  face  was  sallow,  or  of  a  yellowish  cast,  such  as  is  seen  in  cachectic 
persons,  but  not  sufficiently  well-marked  to  attract  attention.  His  wife  said 
that  his  skin  was  sallow,  but  that  no  one  had  voluntarily  remarked  any  change 
of  hue. 


1863.]  Medical  Pathology  and  Therapeutics.  491 


The  patient,  on  admission,  stated  that  he  had  been  ill  six  weeks,  this  being 
the  time  in  which  he  had  been  incapacitated  for  work. 

Autopsy,  by  Dr.  Wilks. — Both  supra-renal  capsules  were  converted  into 
large  masses  of  an  albuminous  substance.  They  were  larger  than  any  which 
had  yet  been  found  at  the  hospital,  and  were  composed  of  a  material  of  a  much 
more  recent  formation  than  had  been  before  observed.  They  had  contracted 
adhesions  to  the  parts  around,  as  to  the  liver,  etc.,  from  which  the  right  one 
had  to  be  torn.  The  right  capsule  was  also  adherent  to  the  vena  cava,  and  the 
coats  of  the  vein  were  involved.  On  opening  this  vessel,  there  was  seen  a 
raised  rough  patch  where  the  coats  had  actually  been  destroyed ;  and  the  dis- 
ease was  penetrating  their  interior.  There  were  also  contiguous  lymphatic 
glands  enlarged.  The  diseased  organs,  or  the  masses  of  material  which  took 
their  place,  were  not  weighed,  in  consequence  of  their  non-removal  from  the 
kidneys,  but  they,  probably  would  have  weighed  as  much  as  two-thirds  the  size 
of  the  kidney  to  which  they  were  attached.  The  substance  composing  the  dis- 
eased organs  was  a  softish  material,  of  a  white  colour,  of  the  consistence  of 
tallow  or  lard.  It  cut  with  a  smooth  surface,  but  was  easily  friable,  and  could 
be  rolled  up  into  a  softish  mass.  It  was  of  the  same  character  as  had  been  met 
with  in  previous  cases,  but  not,  as  in  them,  associated  with  any  yellow  or  so- 
called  tuberculous  or  cretaceous  material.  In  fact,  there  was  no  deposit  within 
them  indicating  that  the  disease  was  of  any  age,  as  it  had  not  undergone  those 
changes  which  time  brings  about.  The  deposit  had,  no  doubt,  been  formed  in 
a  comparatively  short  period.  The  diseased  masses  were  so  contiguous,  and 
the  material  forming  them  so  encroached  on  surrounding  parts,  that  the  semi- 
lunar ganglia  were  more  than  usually  involved.  The  right  one  was  actually 
imbedded  in  the  capsule,  and  many  of  its  nerves  passed  into  it.  The  left  was 
in  contact,  and  its  nerves  merely  involved. — Med.  Times     Gaz.,  Jan.  24,  1863. 

27.  White  Fibro-serous  Discharge  from  the  Thigh. — Dr.  A.  B.  Buchanan 
communicated  to  the  Royal  Medical  and  Chirurgical  Society  (Jan.  27,  1863), 
the  history  of  a  remarkable  case  of  discharge  of  white  fibro-serous  fluid  from  the 
posterior  cutaneous  surface  of  the  thigh,  at  present  under  his  care  in  Glasgow. 
The  patient  was  a  woman,  in  other  respects  in  fair  health,  aged  46,  and  mother 
of  six  healthy  children.  The  discharge  was  white,  like  milk,  and  flowed  from 
excoriations  produced  by  the  rupture  of  small  vesicle's  scattered  over  the  back 
of  the  thigh,  and  particularly  from  an  infiltrated  patch,  of  the  size  of  the  palm 
of  the  hand,  on  which  the  vesicles  and  excoriations  were  most  abundant.  The 
milky  fluid  coagulated  a  few  minutes  after  being  passed.  It  contained  a  fatty 
molecular  base,  similar  to  that  of  chyle,  and  a  few  nucleated  cells.  The  results 
of  a  chemical  analysis  closely  corresponded  with  those  yielded  by  "chylous 
urine."  The  patient  dated  the  commencement  of  her  malady  from  a  shivering- 
fit  twenty-one  years  ago,  shortly  after  which  she  noticed  a  "lump"  in  the  situa- 
tion of  the  affected  surface.  Fifteen  years  ago  vesicles  appeared,  from  which  a 
brownish  fluid  exuded  on  scratching.  For  the  last  six  years  the  discharge  has 
been  milk-white,  and  is  always  worse  in  wet  weather,  and  while  the  patient  is 
walking  about,  when  its  amount  may  be  half  a  pint  per  hour.  At  night  it  ceases 
to  run,  recommencing  about  an  hour  after  the  patient  rises  in  the  morning ;  but 
in  dry  or  frosty  weather  it  may  occasionally  be  absent  for  a  week  or  two.  The 
veins  of  the  affected  limb  are  varicose,  but  no  enlargement  of  the  lymphatic 
glands  can  be  detected.  The  author  succeeded  in  controlling  the  discharge  for 
two  months  by  a  long  elastic  stocking,  the  use  of  which,  however,  had  to  be 
discontinued,  owing  to  severe  lancinating  pains  in  the  thigh.  Immediately  on 
ceasing  to  use  the  stocking  the  uneasy  sensations  subsided,  and  the  discharge 
commenced  anew.  After  remarking  that  cases  of  this  affection  were  extremely 
rare  in  temperate  latitudes,  Dr.  Buchanan  pointed  out,  by  referring  to  several 
recent  examples,  that  they  were  probably  more  frequent  in  warm  climates.  He 
cited,  however,  and  gave  an  account  of  two  unequivocal  cases  of  the  same 
affection,  both  dating  from  the  seventeenth  century,  one  of  which,  in  a  male 
subject,  occurred  in  Germany,  and  the  other,  in  a  female,  in  France.  While  re- 
ferring to  various  pathological  theories,  the  author  fully  recognized  the  identity 
of  the  above  disease  with  "  chylous  urine,"  or,  as  he  would  prefer  to  call  it, 


492 


Progress  of  the  Medical  Sciences. 


[April 


"  white  fibro-serous  urine."  He  objected  particularly  to  the  theory  which  identi- 
fied white  fibro-serous  discharges  in  general  with  chyle.  He  gave  his  reasons 
for  believing  that  it  was  more  natural  to  consider  them  as  equivalent  to  the  white 
liquor  sanguinis — to  transudations  of  the  serum  of  the  blood  during  its  periodical 
milkiness  after  meals,  but  with  certain  modifications  inseparable  from  the  mode 
of  its  secretion.  Thus,  while  the  water,  albumen,  and  salts,  and  possibly  also 
the  fibrin,  would  come  from  the  blood  directly,  he  showed  that  the  cells  present 
in  the  discharge  must  be  derived  from  the  secretory  layer  of  the  skin,  or  from 
the  epithelium  of  cutaneous  glands.  He  contended  that  the  molecular  base  was 
unquestionably  derived  from  the  blood ;  but  that  the  molecules  could  not  be 
conceived  to  filter  directly  through  the  walls  of  the  vessels  without  presuppos- 
ing the  existence  of  a  uniformly  and  intensely  milky  serum  while  the  discharge 
was  flowing,  even  at  long  intervals  after  meals.  To  avoid  this  difficulty,  it  might 
be  supposed  that  the  epithelial  cells  of  the  glands  of  the  skin  had  the  power  of 
separating,  by  a  perverted  function,  fatty  matter  from  the  blood,  much  as  the 
epithelial  cells  of  the  intestine  are  concerned  in  filtering  it  into  the  lacteals. 
The  cells  would  then  become  gorged  with  fatty  molecules,  and  the  uniformly 
white  colour  of  the  discharge  would  be  accounted  for  without  its  being  necessary 
to  suppose  that  the  liquor  sanguinis  was  ever  milky  except,  as  usual  after  meals. 
On  this  view,  white  fibro-serous  discharges  would  depend  immediately  on  de- 
ranged glandular  action,  and  the  foregoing  case  might  be  defined  as  a  rare 
functional  affection  of  the  glandular  apparatus  of  the  skin.  The  paper  was 
illustrated  by  specimens  of  the  milky  discharge,  and  by  a  drawing  of  the  dis- 
eased surface. — Med.  Times  and  Gaz.,  Feb.  7,  1863. 

28.  Urine  in  Hydrophobia. — Dr.  Heller,  in  Wien.  Med.  Wochenschrift, 
gives  the  following  analysis  of  the  urine  of  a  lad  six  years  old,  who  died  of 
hydrophobia.  The  quantity  operated  on  was  about  one  pound.  Its  specific 
gravity  was  1036,  and  very  acid.  The  sediment  consisted  of  uric  acid,  and  was 
in  greater  abundance  than  Dr.  Heller  had  ever  met  with.  No  urate  of  ammonia 
was  found  in  the  sediment.  Of  albumen,  and  of  carbonate  of  ammonia,  there 
was  only  a  trace.  It  contained  no  sugar.  The  uropheine  and  uroxanthine  were 
slightly  increased.  In  the  clear  urine  was  also  contained  much  uric  acid.  The 
urea  was  greatly  increased,  and  was  equal  in  quantity  to  what  is  met  with  in 
meningitis.  The  chlorides  were  very  slightly  diminished ;  the  sulphates  greatly 
increased.  The  earthy  phosphates  were  much,  and  the  alkaline  phosphates 
slightly,  increased. — Brit.  Med.  Journ.,  Jan.  3,  1863. 

29.  Effects  of  Diet  and  Drugs  in  the  Treatment  of  Diabetes  Mellitus. — Dr. 
Andrew  Smart  gives  the  following  results,  obtained  from  a  series  of  observa- 
tions— in  two  cases  of  diabetes  mellitus  treated  by  Dr.  Laycock,  in  the  Royal 
Infirmary,  Edinburgh — instituted  with  the  object  of  determining  the  sugar-pro- 
ducing agency  of  certain  articles  of  diet. 

The  following  articles  are  arranged  in  the  order  in  which  they  were  found, 
Dr.  S.  states,  to  act  as  sugar  producers : — 

"1.  Sugar  (cane),  whether  used  as  an  article  of  diet  or  medication,  besides 
undergoing  transformation  into  grape  sugar,  acted  as  a  powerful  diuretic  and 
stimulant  to  the  morbid  production  of  sugar.    It  also  greatly  increased  thirst. 

"2.  Rice,  contrary  to  general  belief,  was  next  to  sugar  in  its  influence  on  the 
production  of  diabetic  sugar  and  increase  of  urine.  Its  action  in  these  respects 
was  much  greater  than  can  be  explained  by  reference  to  the  proportion  of  starch 
and  sugar  which  it  contains. 

"3.  Potatoes  were  inferior  to  rice  in  their  sugar  and  urine-producing  powers, 
but  exerted  a  markedly  greater  influence  than  the  ordinary  sorts  of  wheaten 
bread. 

"4.  Gluten  Bread. — We  have  not  succeeded  in  ascertaining  the  exact  com- 
position of  the  bread  usually  sold  under  this  name.  It  is  decidedly  sweet  to  the 
taste  (but  this  saccharine  quality  does  not  depend  on  admixture  with  sugar). 
It  is  also  very  palatable,  and  preferred  by  diabetic  patients  to  ordinary  bread. 
It  has  been  much  recommended  in  diabetes,  under  the  belief  that,  as  an  article 
of  food,  it  operated  more  mildly  in  exciting  and  maintaining  morbid  action. 


1863.]  Medical  Pathology  and  Therapeutics. 


493 


This  opinion  was  contra-indicated  by  repeated  and  careful  trials,  the  results  of 
which  demonstrate  that  its  influence  as  a  sugar  eliminator  exceeds  that  of  ordi- 
nary white  and  bran  bread. 

"5.  White  Bread. — The  trials  with  this  bread,  as  with  the  others,  were 
extremely  varied,  but  invariably  with  like  results.  It  undoubtedly  produced 
less  sugar  than  gluten  bread,  but  was  superior  in  that  respect  to  brown  bread 
and  oatmeal.  It  is  interesting  to  know  that  the  amount  of  sugar  found  in  the 
urine  invariably  maintained  a  fixed  relation  to  the  combined  proportions  of 
sugar  and  starch  contained  in  the  bread,  the  proportion  of  diabetic  sugar  always 
exceeding  that  of  the  starch  and  sugar  elements  as  two  to  one.  Thus,  for 
example,  if  the  amount  of  bread  taken  in  twenty-four  hours  contained,  say  500 
grains  of  combined  sugar  and  starch,  and  no  other  substance  interfered  with 
the  experiment,  a  careful  analysis  of  the  urine  during  the  same  period  yielded, 
with  remarkable  uniformity,  nearly  double  that  amount,  i.  e.,  somewhere  about 
1000  grains. 

"  6.  Bran  Bread. — This  bread  differed  in  no  important  particular,  except  in 
its  milder  action  in  the  production  of  sugar.    But  this  difference  was  trivial. 

''7.  Oatmeal. — The  influence  of  this  cereal,  when  given  weight  for  weight 
with  the  others,  was  so  decidedly  less  that  there  can  be  no  doubt  in  placing  it 
last  in  the  list  now  given.  It  diminished  the  amount  of  urine  while  rather 
heightening  its  density,  but,  as  an  article  of*  diet,  it  was  not  relished  by  the 
patients. 

"8.  Eggs. — When  the  patients  were  put  on  an  exclusively  egg  diet,  the 
amount  of  urine  and  sugar  progressively  diminished,  and  the  latter  would  pro- 
bably have  entirely  disappeared  from  the  urine  had  it  been  possible  so  to  restrict 
the  diet  for  a  sufficiently  lengthened  period. 

"  9.  New  Milk  contains  sugar,  as  sugar  of  milk ;  but,  judging  from  all  the 
trials  which  were  made  with  it,  we  were  led  to  infer  that  this  constituent  does  not 
undergo  glucose  transformation.  Under  this,  as  in  egg  diet,  the  sugar  progres- 
sively disappeared  from  the  urine.  But  the  great  difficulty  always  experienced 
was,  to  confine  the  patients  for  some  time  to  one  or  two  kinds  of  food. 

"  10.  Animal  Diet. — When  eggs,  milk,  fish,  beef,  mutton,  and  all  other  kinds 
of  animal  diet,  were  given  either  alone  or  in  combination,  the  following  results 
invariably  followed  :  1.  Marked  decrease  in  the  elimination  of  sugar  and  secre- 
tion of  urine,  which  was  progressive  with  the  continuance  of  the  diet.  2.  Sense 
of  hunger  and  thirst  greatly  lessened.    3.  Increased  density  of  urine. 

"  11.  Vegetables,  such  as  cabbages  and  turnips,  sensibly  augmented  the  pro- 
duction of  sugar,  but  to  a  much  smaller  amount  than  is  generally  supposed. 
They  were  also  apt  to  derange  the  digestive  system.  Cabbage  invariably  pro- 
duced diarrhoea  in  one  of  the  patients,  and  in  the  other  indigestion  and  flatus. 

"  12.  God-liver  Oil  and  Fats. — Their  use  was  followed  by  the  same  results  as 
were  found  in  the  animal  diet  trials ;  but  they  could  not  be  taken  by  the  patients 
for  some  time,  or  in  considerable  quantity,  without  inducing  nausea. 

"  13.  Mixed  Diet. — The  production  of  sugar  under  this  diet,  of  whatever  sub- 
stances it  may  be  composed,  was  found  to  be  invariably  proportional  to  the 
amount  of  sugar  and  starch  contained  in  the  articles  which  were  used.1 

"  II.  Second  Series  of  Trials  to  Determine  the  Influence  of  Remedies  on  the 
Elimination  of  Diabetic  Sugar. 

" 1.  Permanganate  of  Potash,  allayed  thirst,  lowered  the  density,  but  increased 
the  amount  of  the  urine  and  also  of  the  sugar. 

"  2.  Sesquinitrate  of  Iron  stimulated  appetite  for  food  ;  did  not  allay  thirst ; 
did  not  materially  influence  the  amount  of  urine,  but  increased  that  of  the 
sugar. 


1  Porter  and  Ale. — It  is  generally  supposed  that  all  malt  liquors  very  powerfully 
stimulate  to  the  morbid  production  of  sugar  in  diabetes  mellitus  ;  but  the  experi- 
ments made  with  ale  and  porter  do  not  support  that  opinion.  Their  use,  to  the 
extent  of  twelve  or  twenty-four  ounces  daily,  is  attended  with  little  more  than  an 
appreciable  increase  in  the  amount  of  sugar.  The  rate  of  increase,  as  in  the  other 
articles,  was  ascertained  and  recorded. 


494 


Progress  of  the  Medical  Sciences.  [April 


"3.  Glycerine  markedly  increased  thirst  and  the  amount  of  urine;  lowered 
density  of  urine,  but  total  amount  of  sugar  greatly  increased. 

"4.  Chloroform. — This  was  exhibited  by  inhalation,  which  was  repeated  every 
two  hours  during  the  experiment.  Quantity  of  urine  greatly  increased ;  its 
density  lowered,  but  total  amount  of  sugar  in  twenty-four  hours  increased. 
Chloroform  increases  sugar  simply  by  acting  as  a  diuretic. 

"5.  Sulphuric  and  Chloric  Ethers. — Both  these  agents  operate  as  chloro- 
form, but  in  a  much  less  marked  degree. 

"6.  Strychnia. — The  experiments  with  this  powerful  agent  were  begun  by 
administering  ^th  of  a  grain  thrice  daily,  and  the  dose  progressively  increased 
until  its  physiological  action  on  the  nervous  system  became  incipiently  appa- 
rent. 

''The  result  was  a  progressive  and  commensurate  decrease  in  the  amount  of 
urine  and  sugar.  The  patients'  diet  during  the  course  of  this  and  the  other 
trials  of  remedies  was  uniform.  The  patients'  general  health  was  good,  and 
they  gained  weight." — Med.  Times  and  Gaz.,  Feb.  14,  1863. 

30.  Diabetes. — Dr.  Muller,  of  Hanover,  read  a  paper  before  the  Congress  of 
German  Naturalists  and  Physicians  at  their  last  meeting,  on  diabetes,  with 
details  of  thirty-one  cases  observed  by  him :  twenty-three  of  the  patients  were 
men,  and  only  eight  women.  Amongst  the  causes,  masturbation  was  most 
frequent.  Twelve  of  the  patients  died,  nine  of  them  rapidly,  of  tubercular 
disease,  and  three  of  Bright's  disease.  As  regards  the  treatment,  animal  food 
and  gluten  had  proved  very  unsatisfactory,  and  a  mixed  diet  was  far  preferable. 
Tannin,  either  alone,  or  with  aloe  and  rheum,  gave  good  results,  and  small 
doses  of  opium  at  night  were  advisable.  The  use  of  the  thermal  springs  of 
Carlsbad  produced  amelioration  in  every  one  of  the  cases ;  but  the  benefit  was 
not  permanent:  in  one  case  it  lasted  for  nineteen  months,  in  another  for  ten 
months.  The  largest  quantity  of  urine  observed  amounted  to  nineteen  and  a 
half  quarts,  the  largest  quantity  of  sugar  to  ten  per  cent. ;  the  highest  specific 
gravity  was  1.058.  In  five  cases  there  was  amblyopia  and  morbus  Brightii.  An 
animated  discussion  followed  the  reading  of  this  paper,  and  several  of  the  Carls- 
bad physicians  communicated  their  experience  on  the  use  of  the  waters  of  this 
place.  Professor  Seegen  said  that  he  had  treated  more  than  forty  cases  of 
diabetes  with  Carlsbad  water,  that  there  had  been  a  diminished  amount  of  urine 
and  sugar,  and  the  weight  of  the  body  had  become  augmented,  but  a  complete 
cure  had  never  been  effected.  Most  of  the  patients  in  question  used  the  Carls- 
bad treatment  for  several  years  successively,  and  each  time  with  benefit.  The 
improvement  was  generally  rapid,  and  lasted  for  a  considerable  time.  Dr. 
Fleckles  said  that,  if  diabetes  was  complicated  with  anaemia,  the  use  of  Franz- 
ensbad,  Pyrmont,  or  Spa,  was  advisable  after  a  course  of  the  Carlsbad  treat- 
ment.— Med.  Times  and  Gaz.,  Dec.  13,  1862. 

31.  Action  of  Sesquichloride  of  Iron  on  Phthisis— Dr.  Richard  Payne 
Cotton  administered  the  sesquichloride  of  iron  in  twenty-five  cases  of  uncom- 
plicated phthisis  furnished  by  his  own  wards  in  the  Consumption  Hospital.  Of 
this  number,  eight  were  males,  and  seventeen  females.  Eleven  were  in  the  first, 
four  in  the  second,  and  ten  in  the  third  stage  of  the  disease.  None  of  the  cases 
presented  any  very  remarkable  feature,  all  of  them  being  examples  of  the  ordi- 
nary run  of  patients  affected  with  chronic  consumption,  care  having  been  taken 
to  exclude  those  in  whom  there  existed  either  any  special  complication  or 
secondary  affection  which  demanded  a  different  treatment. 

The  dose  consisted  often  or  fifteen  minims  of  the  tinctura  ferri  sesquichloridi 
administered  in  water  two  or  three  times  a  day,  and  was  continued  for  periods 
varying  from  three  weeks  to  four  months.  Cod-liver  oil  was  also  taken  some- 
times by  a  few  of  the  patients ;  but,  as  a  general  rule,  this  substance  was 
avoided,  at  least  temporarily,  with  the  view  of  not  complicating  the  result. 

Twelve  patients  improved  greatly,  five  improved  slightly,  and  eight  experi- 
enced no  relief  whilst  under  treatment.  Ten  of  the  seventeen  more  or  less  im- 
proved cases  did  not  take  any  cod-liver  oil ;  but,  by  subsequent  observations,  it 


1863.]  Medical  Pathology  and  Therapeutics. 


495 


was  sufficiently  evident  that  the  greatest  good  was  brought  about  by  the  com- 
bined influence  of  these  two  substances. 

Were  I  to  be  asked  from  which  of  the  ten  medicinal  agents  already  experi- 
mented upon,  I  had  observed  the  most  benefit,  I  should  unhesitatingly  fix  upon 
the  sesquichloride  of  iron.  For  some  years,  indeed,  I  have  been  in  the  habit  of 
using  this  substance  extensively,  both  in  private  and  hospital  practice,  and  some 
of  the  most  happy  results  I  have  met  with  in  the  treatment  of  phthisis  have 
certainly  taken  place  during  its  administration.  In  no  instance  have  I  seen 
any  reason  to  connect  with  its  use  the  occurrence  either  of  haemoptysis,  or  any 
other  active  symptom.  In  passive  haemoptysis,  indeed,  I  have  often  found  it  a 
very  useful  remedy;  whilst  it  often  helps  to  check  excessive  secretion,  whether 
from  the  skin  or  the  mucous  surfaces.  • 

The  following  are  Dr.  Cotton's  conclusions,  derived  from  his  experience,  as  to 
the  effects  of  iron  upon  phthisis : — 

"  1.  That  iron  is  a  very  valuable  remedy  in  consumption — perhaps  more  valu- 
able than  any  other  with  which  we  are  at  present  acquainted. 

"2.  That  of  the  numerous  preparations  of  iron,  the  sesquichloride  is  the  best, 
its  astringent  nature  being  generally  well  suited  to  many  symptoms  of  the  con- 
sumptive patient." — Med.  Times  and  Gaz.,  Jan.  24,  1863. 

32.  Use  of  the  Alkaline  Lactates  and  of  Pepsin  in  Indigestion. — Dr.  Pe- 
trequin, of  Lyons,  advises  the  employment  of  the  alkaline  lactates,  and  espe- 
cially those  of  soda  and  magnesia,  in  the  treatment  of  the  functional  disorders 
of  the  digestive  canal.  He  was  induced  to  try  these  salts  in  the  treatment  of 
dyspepsia,  because  they  are  natural  to  the  digestive  tube,  and  the  alkaline 
compound  which  results  from  their  use  is  an  integral  part  of  the  chemical  ele- 
ments of  digestion.  Practical  investigations  have  confirmed  these  theoretical 
views,  and  an  experience  of  twelve  years  has  convinced  Dr.  Petrequin  that  the 
use  of  the  alkaline  lactates  promotes  the  flow  of  the  digestive  juices,  regulates 
their  secretion,  renders  the  digestive  function  normal,  and  restores  the  languid 
or  perverted  action  of  the  stomach  and  intestine  by  enabling  them  to  produce 
regularly  the  liquids  necessary  for  the  digestive  process.  The  lactate  of  soda 
is  very  soluble  in  water,  and  crystallizes  only  with  difficulty,  and  as  it  is  very 
deliquescent  it  is  prepared  with  sugar,  which  enables  it  to  be  preserved.  The 
lactate  of  magnesia  has  been  obtained  in  silky  masses,  which  are  very  light, 
very  white,  and  composed  of  very  slender  crystals ;  it  is  unalterable  in  the  air, 
of  sparing  solubility,  and  without  smell  or  taste.  Dr.  Petrequin  employs  the 
alkaline  lactates  in  the  disorders  occurring  in  any  of  the  three  principal  phases 
of  digestion — namely,  the  buccal,  the  stomachal,  or  the  intestinal.  In  the  first, 
the  disorder  may  depend  either  on  the  alteration  of  the  saliva,  which  may  be- 
come acid,  or  on  the  diminution  of  the  secretion  of  this  fluid.  In  both  cases 
the  patient  should  take,  before  meals,  two  or  three  pastilles,  which  should  be 
slowly  melted  in  the  mouth,  and  the  same  should  be  done  after  meals.  The 
disorders  which  correspond  to  the  stomachal  or  gastric  phase  of  dyspepsia  are 
more  numerous,  and  require  some  modifications  in  the  use  and  administration  of 
the  medicine.  In  the  acid  dyspepsia,  Dr.  Petrequin  advises  a  combination  of 
lactate  of  magnesia  and  of  lactate  of  soda  with  sugar ;  and  in  what  he  calls 
neutral  dyspepsia,  which  he  attributes  to  deficiency  of  the  gastric  juice,  he 
combines  pepsin  with  the  powders  or  pastilles.  During  intestinal  digestion,  the 
alkaline  lactates  may  still  be  advantageously  employed,  although  the  functional 
lesions  of  the  intestine  are  generally  less  easily  accessible  to  our  remedies  than 
those  of  the  stomach.  "  We  know,"  says  Dr.  Petrequin, "  that  magnesia  produces 
excellent  results  in  the  diarrhcea  of  children  at  the  breast,  and  the  alkaline 
lactates  are  no  less  efficacious.  I  have  also  observed  their  curative  powers  in 
the  diarrhcea  which  supervenes  in  convalescent  patients,  when  they  resume  the 
use  of  food,  and  when  their  stomach  is  still  weakened.  I  have  also  several 
times  employed  them  successfully  in  the  diarrhcea  of  persons  who  were  ener- 
vated by  excessive  fatigue ;  and  I  have  observed  the  same  results  in  enteralgia, 
enteric  flatulence,  and  the  purging  which  is  symptomatic  of  intestinal  indiges- 
tion."— Brit,  and  For.  Med.-Chirurg.  Rev.,  Jan.  1863,  from  L'  Union  Me'dicale, 
Aug.  21,  1862. 


496  Progress  of  the  Medical  Sciences.  [April 


33.  Taenia  treated  by  Areca  Nut. — Dr.  Edwin  Morris  communicated  to 
the  Midland  Branch  of  the  British  Med.  Assoc.  the  following  case  of  this: — 

John  T.,  aged  46  years,  for  several  weeks  past  had  been  losing  flesh,  had 
occasional  headaches,  nausea,  and  feeling  of  faintness,  with  loss  of  appetite. 
The  month  of  April  last,  he  had  passed  several  pieces  of  tapeworm.  After 
fasting  from  breakfast  the  previous  day  on  April  30th,  at  6  A.  M.,  four  drachms 
of  powdered  areca  nut  was  taken  in  milk.  "Within  two  hours  afterwards  he 
passed  six  yards  and  a  half  of  worm.  For  more  than  a  week  afterwards,  no 
more  worm  coming  away,  four  drachms  more  of  the  areca  were  taken  in  a  similar 
manner.  Within  an  hour  six  yards  more  of  worm  were  passed.  From  the  flat 
regular  size  of  the  worm,  it  was  evident  that  the  head  had  not  yet  been  expelled. 
After  previously  fasting,  a  purgative  was  given ;  and  early  the  next  morning 
six  drachms  of  the  areca  were  given  as  before,  and  in  a  quarter  of  an  hour  two 
yards  and  a  half  more  worm  were  passed  alive,  making  altogether  fifteen  yards, 
Upon  examining  the  worm,  it  gradually  tapered  down  to  a  small  bulb  about 
the  size  of  a  pin's  head.  The  man  has  been  much  better  since,  and  no  more 
joints  have  been  passed. 

Dr.  Morris's  attention  was  first  called  to  the  use  of  the  areca  nut  in  taenia  by 
the  article  of  Dr.  Barclay  in  British  Med.  Journ.,  Aug.,  1861. 

Dr.  M.  remarks  that  for  the  expulsion  of  tapeworm  a  variety  of  remedies 
have  been  used — and  successfully.  Those,  however,  which  have  been  found  of 
the  greatest  service  have  been  oil  of  turpentine,  kousso,  oil  of  male  fern,  and 
lastly,  areca  nut.  Whatever  remedy  is  used,  it  will  be  utterly  useless  unless 
the  head  is  expelled ;  for  the  worm  renews  itself  rapidly  after  portions  of  it 
have  been  removed,  by  the  formation  of  new  joints  at  its  neck;  and  will  very 
soon  regain  its  original  size.  It  therefore  follows  that  those  medicinal  sub- 
stances which  expel  the  head,  are  the  most  valuable.  It  is  a  singular  fact  that 
few  medical  men  have  ever  seen  the  head  of  the  tapeworm,  notwithstanding  that 
the  disease  is  frequent  enough.    *  * 

If  you  will  take  the  trouble  to  examine  the  preparation  I  have  placed  before 
you,  and  observe  the  thread-like  substance  of  the  neck  to  which  the  head  is 
attached,  you  will  not  wonder  at  the  difficulty  there  is  in  finding  the  head,  and 
how  rarely  it  is  obtained ;  you  will  be  more  likely  to  succeed  in  expelling  the 
head,  if  a  brisk  purgative  is  given  before  the  areca  is  taken. 

I  was  fortunate  in  having  obtained  so  long  a  piece  of  the  neck  of  the  worm, 
as  it  enabled  me  to  easily  find  the  head  when  placed  in  water ;  having  removed 
the  head  with  a  portion  of  the  neck  attached,  and  placed  it  under  the  micro- 
scope with  a  one-inch  power,  I  readily  examined  it  as  a  transparent  object.  The 
neck  is  narrow  and  flat,  terminated  by  a  small  bulb  (cephalic  bulb)  with  black 
specks,  which  is  the  head  of  the  worm ;  upon  carefully  examining  the  specks, 
they  are  found  to  be  the  four  suckers,  and  are  funnel-shaped  and  easily  recog- 
nized. The  necks  of  the  two  extreme  suckers  ramify  in  various  directions,  and 
appear  to  join  the  other  suckers.  Upon  using  a  higher  power  (Smith  and 
Beck's  fifth)  several  hooklets  may  be  seen,  by  which  the  worm  attaches  itself 
to  the  mucous  membrane  of  the  bowel  before  applying  its  suckers.  I  have 
made  a  sketch  of  the  head  as  it  appears  under  the  microscope,  which  gives  a 
tolerably  accurate  representation  of  the  head  with  its  four  suckers  and  hooklets. 

[The  seed  of  the  common  pumpkin  beaten  into  a  pulp  witli  sugar,  and  taken 
in  the  morning  fasting,  is  a  very  reliable  remedy  for  taenia.  We  have  used  it 
with  complete  success. — Editor.] 


SURGICAL  PATHOLOGY  AND  THERAPEUTICS,  AND  OPERATIVE 

SURGERY. 

34.  Traumatic  Tetanus  successfully  treated  by  Nicotine. — In  our  previous 
number  (p.  221)  allusion  was  made  to  a  case  of  tetanus  successfully  treated  at 
Baggot  St.  Hospital  by  nicotine.    Mr.  Tufnell  has  since  communicated  to  the 


1863.] 


Surgery. 


497 


Surgical  Society  of  Ireland  a  history  of  the  case,  which  we  extract  from  our 
contemporary,  the  Dublin  Medical  Press  (January  7,  1863) : — 

"J.  D.,  set.  42,  a  tall,  muscular  man,  a  sewer  maker,  of  very  intemperate  habits, 
was  brought  to  the  City  of  Dublin  Hospital  on  the  evening  of  the  28th  of  Feb- 
ruary, 1862,  suffering  from  a  severe  compound  fracture  of  the  right  radius,  three 
inches  above  the  wrist.  The  accident  had  occurred  about  twenty  minutes  be- 
fore admission,  and  was  occasioned  by  the  falling  of  a  heavy  flagstone  upon  \he 
forearm.  There  was  a  good  deal  of  laceration  of  the  soft  parts,  and  considerable 
hemorrhage.  The  wound,  which  was  three  inches  long  and  triangular  in  shape, 
had  its  base  to  the  ulna,  and  was  filled  with  blood  and  clay :  the  upper  end  of 
the  lower  fragment  of  the  radius  was  thrown  outwards  upon  the  ulna  ;  the  hand 
was  pronated  and  curved  inwards. 

"The  wound  having  been  carefully  cleansed,  the  fracture  was  adjusted,  and 
the  arm  placed  upon  a  pistol  splint ;  water-dressing  with  flannel-tailed  bandage 
surrounding  all.  Win|  arid  an  opiate  were  given.  Everything  went  on  well 
until  the  evening  of  the  12th  of  March,  when  the  patient  said  that  he  thought 
he  must  have  caught  cold,  as  he  had  pain  and  soreness  about  the  jaws,  with 
difficulty  of  mastication.  He  had  also  a  peculiar  tendency  to  sigh.  Shortly 
afterwards  he  complained  of  pain  in  the  left  mammary  region,  and  the  abdominal 
muscles,  when  examined,  were  found  somewhat  tense.  There  was  at  this  time 
no  rigidity  of  the  forehead,  eyelids,  or  mouth.  The  pulse  was  soft,  regular,  and 
natural  at  68,  the  respiration  normal,  and  the  bowels  had  been  acting  regularly. 
He  was  ordered,  however,  a  bolus  of  five  grains  of  calomel  with  one  drachm  of 
compound  powder  of  jalap. 

"On  the  following  day  (13th),  the  facial  muscles  exhibited  the  characteristic 
contractions  of  tetanus.  The  trismus  was  now  determined,  and  the  cervical 
muscles,  especially  upon  the  right  side  (that  of  the  accident),  engaged.  The 
right  rectus  abdominis  was  more  tense  than  the  left.  The  bowels  had  been 
freely  acted  on  by  the  aperient,  and  the  discharges  were  not  dark. 

"He  was  now  ordered  to  take  one  drachm  of  chloroform  agitated  with  an 
ounce  and  a  half  of  linseed  tea  every  fourth  hour,  and  a  bag  of  ice  directed  to 
be  applied  to  the  cervical  spine.  The  wound  was  looking  healthy,  and  begin- 
ning to  cicatrize  at  the  edges. 

"Upon  the  14th  there  was  an  advance  in  the  symptoms  which  seemed  to  be 
kept  partially  at  bay  only  by  the  chloroform.  The  muscles  of  the  neck  and 
abdomen  had  become  exceedingly  tense,  and  there  was  pain  through  the  attach- 
ments of  the  diaphragm.  The  muscles  of  the  extremities,  too,  were  now  attacked 
by  clonic  spasms.    The  pulse  had  increased.    Chloroform  was  continued. 

"Upon  the  15th  he  was  worse.  The  masseter  muscles  and  sterno-mastoids 
were  very  rigid,  and  the  respiration  was  rendered  difficult  by  the  viscid  mucus 
which  accumulated  in  the  bronchi,  and  could  not  be  got  rid  of  by  expectoration. 
(He  had  previously  suffered  frequently  from  bronchitis.)  He  could  swallow 
liquids,  but  with  great  difficulty.  As  the  bowels  had  not  acted  since  the  13th,  a 
purgative  enema  was  ordered,  and  the  chloroform  directed  to  be  given  more  fre- 
quently; every  third  or  second  hour  as  required. 

"On  the  16th  the  symptoms  were  unaltered,  but  the  pulse  was  becoming  fre- 
quent, rising  to  90  during  the  paroxysms  of  pain.  The  chloroform  having  been 
administered  for  three  days,  and  the  case  not  beginning  to  improve,  it  was 
determined  to  employ  nicotine,  and  the  Eev.  Professor  Haughton  having  kindly 
brought  some  of  that  prepared  under  his  own  direction,  the  strength  of  a  single 
drop  of  which  is  equivalent  to  23.2-10th  grains  of  Virginian  Cavendish  tobacco, 
the  first  dose  was  administered  at  eight  P.  M. :  one  drop  being  dissolved  in  a 
dessert-spoonful  of  white  wine  mixed  with  an  equal  quantity  of  water.  The 
pulse,  prior  to  the  nicotine  being  given,  was  72 ;  it  speedily  rose  to  84,  and 
within  forty  seconds  of  the  medicine  being  swallowed,  the  whole  surface  of  the 
body  was  bedewed  with  sweat.  The  welling  up  of  the  perspirable  fluid  through 
the  pores  of  the  skin  was  remarkable,  it  being  absolutely  perceptible ;  these 
drops  of  fluid  being  so  large  that  they  might  easily  be  flicked  with  the  hand  from 
off  the  forehead.  The  spasms  almost  immediately  relaxed,  the  corrugation  of 
the  brow  and  frightened  expression  of  countenance  disappearing.  This  improve- 
ment was.  however,  only  transient,  and  the  nicotine  was  repeated  every  two 
No.  XC—  April  1863.  32 


498 


Progress  of  the  Medical  Sciences. 


[April 


hours  up  to  two  A.  M..  when,  in  consequence  of  the  unpleasant  taste  and  nau- 
seating effects,  the  patient  refused  to  take  any  more.  At  six  A.  M.  he  consented, 
however,  and  continued  to  do  so  regularly  every  two  hours,  the  dose  being 
increased  to  two  drops,  or  nearly  a  drachm  of  Cavendish  tobacco.  The  stools 
brought  away  by  the  turpentine  injection  were  for  the  first  time  dark,  green,  and 
fetid.  From  the  commencement  of  the  attack  a  most  liberal  allowance  of  nour- 
ishment, in  the  shape  of  essence  of  beef,  jelly,  and  wine,  had  been  allowed,  which 
was  still  continued,  although  swallowed  with  great  difficulty,  and  got  down  be- 
tween the  wedges  which  separated  the  molar  teeth.  Fomentations  of  a  strong 
decoction  of  tobacco  were  applied  over  the  abdomen,  and  with  apparently  some 
good  effect ;  a  liniment  of  croton  oil  was  also  rubbed  over  the  surface  ;  and  the 
wounded  arm  enveloped  in  a  soft  anodyne  linseed  poultice,  made  with  a  drachm 
of  the  extract  of  belladonna  dissolved  in  a  pint  of  boiling  water. 

;'18th.  Seven  days  had  passed  over  since  the  first  symptoms  had  exhibited 
themselves  and  two  since  the  nicotine  had  been  employed.  All  matters  were 
now  aggravated.  The  patient  had  become  ungovernable,  and  would  take  no 
medicine  by  the  mouth,  and  fluid  of  any  kind  he  could  hardly  swallow.  The 
spasms  were  increased  in  intensity,  of  opisthotonic  character,  and  recurring  at 
intervals  of  eight  minutes.  The  breathing  was  very  quick  and  laboured,  being 
44  per  minute,  and  the  face  congested  from  mucus,  which  was  kept  churning  up 
and  down  in  the  trachea ;  the  pulse  130  in  the  minute ;  the  surface  of  the  body 
wet  and  cold.  As  it  was  impossible  to  give  the  medicine  by  the  mouth,  a  couple 
•of  drops  of  nicotine  were  added  to  a  glass  of  wine  and  water  and  injected  into 
the  rectum  and  held.  The  spasms  relaxed  under  its  influence,  the  power  of 
expectorating  returned,  and  the  heart's  action  became  regular  again.  Towards 
the  afternoon  delirium  set  in,  and  the  patient  now  acquired  full  voluntary  power 
over  the  muscles  of  the  arms  and  legs.  He  endeavoured  to  get  out  of  bed,  and 
struck  wildly  at  those  around  him,  and  was  so  violent  that  it  was  necessary  to 
put  him  under  the  influence  of  chloroform  by  inhalation,  which  was  soon  accom- 
plished, to  the  great  relief  of  the  patient,  who  afterwards  rested  quietly  for  some 
time.  He  was  conscious  on  awaking,  and  asked  for  water  to  be  given  him  to 
drink.  He  was,  however,  so  much  exhausted  that  two  ounces  of  whisky,  with 
an  equal  quantity  of  warm  water,  were  thrown  up  the  rectum  and  retained,  after 
which  he  took  some  strong  beef-tea  by  the  mouth.  During  the  violence  of  the 
patient,  the  fractured  radius  became  bent  almost  to  a  right  angle  with  the  ulna, 
and  the  deformity  of  the  arm  was  consequently  extreme.  An  attempt  was  now 
made  to  remedy  this  deformity,  but  such  aggravation  of  the  symptoms  was  im- 
mediately produced  that  it  was  necessary  to  discontinue  the  effort,  and  the  arm 
allowed  to  assume  the  position  the  patient  chose,  a  scruple  of  watery  extract  of 
opium  dissolved  in  four  ounces  of  water  being  first  applied  (by  means  of  lint 
saturated  with  this  lotion)  to  the  wound.  The  bowels  being  now  confined,  an 
enema  of  turpentine,  assafcetida,  and  castor  oil  was  ordered  to  be  administered, 
which  secured  the  discharge  of  some  dark-green  fetid  stools. 

"19th.  The  nicotine  in  two-drop  doses  was  now  injected  by  the  rectum  regu- 
larly every  second  hour,  the  patient  being  supported  by  wine,  beef-tea,  and 
essence  of  meat,  introduced  through  the  opening  left  between  the  wedges  placed 
between  the  molar  teeth.  Tobacco  fomentations  were  applied  to  the  abdomen 
of  the  strength  of  a  drachm  to  a  pint  of  boiling  water. 

"20th.  Patient  complained  to-day  of  great  pain  in  the  biceps  muscle  of  the 
affected  arm,  and  also  under  the  scapula  of  that  side.  Suffocative  catarrh  was 
also  present.  A  mustard  plaster  enveloping  the  whole  chest  was  ordered  to  be 
applied,  and  the  whisky  enemeta  repeated,  the  nicotine  being  continued  in  injec- 
tion every  two  hours.  The  discharge  from  the  wound  was  now  purely  sanguine- 
ous, and  all  attempt  at  cicatrization  had  for  some  while  ceased.  The  retraction 
of  the  anus  was  now  so  great  as  to  render  the  introduction  of  the  enema-tube  an 
act  of  much  difficulty. 

"22d.  The  fifty-sixth  drop  and  the  last  dose  of  nicotine  administered  to-day, 
the  countenance  being  placid,  and  no  spasm  having  occurred  for  some  hours. 
There  was  great.aching  pain  in  the  lumbar  region  and  soreness  of  the  muscles 
generally,  especially  on  the  right  side  of  the  body.  The  urine  passed  to-day 
contained  a  highly  latcritious  deposit,  but  did  not  possess  the  smell  of  nicotine; 


1863.] 


Surgery. 


499 


patient  very  weak.  He  was  now  ordered  an  injection  consisting  of  five  grains 
of  quinine,  the  yelk  of  am  egg,  an  ounce  of  whisky,  and  three  ounces  of  milk  to 
be  administered  every  sixth  hour. 

"23d.  The  power  to  open  the  mouth  to  some  slight  extent  had  returned. 
The  discharge  from  the  wound  showed  signs  of  purulent  secretion. 

"24th.  Patient  not  so  well;  pulse  varying  in  force  and  rapidity  from  104  to 
140 ;  he  had  pain  in  the  diaphragm  and  occasional  spasms  ;  the  discharges  ff  om 
the  bowels  brought  away  by  an  oil  draught  given  over  night  were  black  and 
offensive.  The  aperient  was  repeated  by  the  mouth  with  a  full  dose  of  opium 
shortly  after. 

"2Gth.  Better,  though  very  weak. 

"28th.  Slept  well;  was  free  from  pain  and  spasm,  and  the  wound  looking 
florid  and  healing  in.    The  quinine  injection  repeated  night  and  morning. 

"31st.  Considerable  soreness  of  the  abdomen  and  diaphragmatic  region  being 
complained  of,  a  large  belladonna  plaster  was  directed  to  be  applied  over  it. 

"From  this  date  the  recovery  was  gradual  and  progressive,  and  he  was  dis- 
charged from  hospital  in  good  general  health,  and  with  partial  use  of  the  injured 
arm,  on  the  10th  of  May. 

"That  the  man  owes  his  life  mainly  to  the  narcotine,  I  think  must  be  fairly 
assumed,  for  under  the  use  of  chloroform  he  was  gradually  getting  worse,  and 
the  spasm  not  coming  under  control.  It  is  true  that  for  a  considerable  period 
after  commencing  the  narcotine  treatment  the  disease  progressed  in  intensity; 
but  still  a  decided  impression  and  relaxation  of  spasm  followed  upon  each 
separate  employment  of  the  remedy.  To  chloroform,  however,  I  was  greatly 
indebted  for  the  power  which  it  gave  me  in  controlling  the  violence  of  the  deli- 
rium, and  obtaining  for  the  patient,  and  his  attendants,  rest." 

35.  New  Methods  of  Discovering  the  Presence  of  a  Ball  or  other  Metallic  Body 
ivithin  a  Wound — Nelaton's  Porcelain  Probe — Favre's  Galvanic  Probe. — The 
difficulties  which  have  attended  the  diagnosis  of  General  Garibaldi's  wound,  and 
the  contradictions  of  surgical  opinion,  have  had  the  good  effect  of  stimulating 
ingenuity  for  the  devising  of  new  and  more  certain  methods  of  physical  explo- 
ration. It  will  be  recollected  that  the  positive  opinion  of  the  presence  of  the 
ball  in  Garibaldi's  wound  given  by  M.  Nelaton  was  based  upon  the  dull  character 
of  the  sound  elicited  when  the  probe  struck  against  the  hard  substance  at  the 
bottom,  which  was  very  different  in  his  experience  from  the  clear  sound  elicited 
from  a  piece  of  necrosed  bone  under  similar  circumstances,  and  also  upon  the 
sensation  imparted  to  the  hand,  which  bore  no  resemblance  to  that  imparted  by 
the  rough  surface  of  a  carious  bone.  On  his  return  to  Paris,  he  devised,  in 
conjunction  with  M.  Em.  Rousseau,  a  contrivance  by  which  a  portion  of  the 
ball  might  actually  be  brought  away,  so  as  to  convince  those  who  differed  from 
him  in  opinion.  This  instrument  consisted  of  a  probe,  furnished  at  the  extremity 
with  a  little  sphere  of  unglazed  porcelain  or  biscuit-ware,  about  the  size  of  a 
small  pea.  On  bringing  this  sphere  in  contact  with  a  leaden  ball,  and  exercising 
a  little  rotatory  friction,  it  acquires  a  stain  of  the  metal,  which  subsequent  con- 
tact of  the  soft  parts  and  morbid  secretions  fails  to  remove.  There  is  this 
additional  advantage,  that  the  portion  of  metal  thus  removed  may  be  dissolved 
off,  and  made  the  subject  of  chemical  tests.  It  was  by  the  use  of  this  little 
instrument  that  Dr.  Zanetti  convinced  himself  of  the  presence  of  the  ball  with 
sufficient  certainty  to  lead  to  a  determination  to  extract  it.  The  credit  of  ano- 
ther contrivance,  more  complicated  but  not  less  ingenious,  is  due  to  the  fertile 
brain  of  M.  Favre,  Professor  of  Chemistry  to  the  Faculty  of  Sciences  of  Mar- 
seilles. The  principle  involved  is  the  different  conducting  power  for  electricity 
between  a  metallic  substance,  on  the  one  hand,  and  the  fluids  and  tissues  of  the 
body,  on  the  other.  Thus  it  happens,  that  if  the  conducting  wire  of  a  feeble 
galvanic  circuit  connected  with  a  galvanometer  be  broken,  and  a  bullet  or  other 
metallic  body  be  interposed,  on  the  completion  of  the  circuit  the  needle  will  be 
strongly  deflected.  This  would  not  be  the  case  on  interposing  the  ordinary 
tissues  of  the  body.  With  the  assistance  of  M.  Favre.  Dr.  Fontan,  a  military 
surgeon  at  Marseilles,  has  made  experiments  to  test  the  efficiency  of  the  plan 
proposed  by  the  former.    The  apparatus  used  was  as  follows  :  1.  A  Smee's  bat- 


500 


Progress  of  the  Medical  Sciences. 


[April 


tery  of  a  single  pair  of  plates,  so  feeble  as  to  be  unable  to  produce  any  sensible 
amount  of  electrolysis  with  the  animal  tissues.  2.  A  galvanometer.  3.  A  probe, 
formed  in  the  following  manner :  it  consisted  of  two  parts,  one  of  which  is  re- 
ceived into  the  other,  which  forms  thus  an  outer  casing.  The  internal  portion, 
or  galvanic  portion,  is  a  straight  metallic  probe,  through  the  length  of  which 
pass,  packed  in  silk,  two  metallic  wires,  each  terminating  in  a  steel  needle,  and 
isolated  and  firmly  fixed  beyond  the  extremity  of  the  probe  by  means  of  a  little 
cone  of  ivory.  These  wires  are  intended  to  conduct  the  galvanic  current,  the 
galvanometer  being  placed  in  the  course  of  the  intended  circuit.  For  this  inner 
probe,  there  is  provided  an  external  metallic  casing,  so  constructed  as  to  permit 
the  galvanic  probe  to  be  slid  within  it,  and  perforated  at  its  extremity  with  two 
holes,  through  which  the  needle-points  of  the  conducting  wires  can  be  protruded. 
There  are  various  little  arrangements  of  grooves,  slits,  and  a  screw  to  insure 
accuracy  of  adaptation  between  the  galvanic  probe  and  its  case.  In  using  the 
instrument,  the  internal  probe  is  retracted  and  fixed  by  the  little  screw,  and  the 
instrument  is  then  employed  in  the  ordinary  way  as  a  probe.  On  the  solid  sub- 
stance being  arrived  at,  the  screw  is  loosened,  the  needle-points  protruded,  and 
brought  into  contact  with  it,  by  sliding  down  the  internal  probe.  If  the  sub- 
stance be  metallic  the  circuit  is  established,  and  the  galvanometer  deflected. 
The  first  experiments  were  made  with  wires  unprovided  with  needle-points,  the 
addition  of  which  were  found  essential  to  success,  inasmuch  as  they  readily 
penetrated  any  soft  tissues  or  adventitious  substances,  pieces  of  clothing,  lea- 
ther, etc*,  which  might  chance  to  be  interposed,  and  also  overcame  the  difficulty 
likely  to  result  from  oxidation  of  the  surface  of  the  metallic  substance,  etc. 
The  use  of  a  little  friction  with  the  point  of  the  sound,  or  a  gentle  percussion 
upon  it,  never  failed  to  establish  the  galvanic  current.  M.  Fontan  suggests 
that,  by  modification  of  this  probe,  the  principle  involved  might  be  applied  to 
other  purposes  of  diagnosis,  as  where  the  presence  of  metallic  bodies  in  the 
canals  or  mucous  cavities  of  the  body  was  to  be  detected. — Med.  Times  and 
Gaz.,  Dec.  13,  1862. 

36.  Wire  Compress :  a  Substitute  for  the  Ligature. — Mr.  John  Dix  read 
before  the  Royal  Medical  and  Chirurgical  Society  (Jan.  13,  1863)  an  account 
of  the  wire  compress,  a  modification  of  the  method  of  arresting  hemorrhage, 
devised  by  Dr.  Simpson.  This  "acupressure,"  he  said,  had  been  tested  by  but 
few  surgeons  of  note;  and  in  London,  especially,  it  is  almost  unknown  and 
ignored.  Although,  probably,  a  real  improvement  on  the  ligature,  it  undoubt- 
edly labours  under  certain  inherent  disadvantages,  most,  or  all,  of  which  (it  is 
believed)  are  obviated  by  the  use  of  a  fine  wire  of  iron  or  of  silver,  instead  of 
the  steel  needles  of  Dr.  Simpson.  This  idea  was  first  promulgated  in  a  paper 
on  "  Acupressure,"  published  in  the  Medical  Times  and  Gazette  of  June  2, 
1860 ;  and  first  put  to  proof  in  a  case  of  amputation  of  the  finger,  September, 
1860.  In  this  operation  two  arteries  were  secured  by  wire,  which  was  removed 
on  the  third  day.  The  case  did  well :  there  was  no  bleeding,  and  very  slight 
suppuration.  In  the  next  case — Ohopart's  amputation,  performed  April  26, 
1861 — five  wires  were  applied  on  as  many  arteries:  four  of  these  were  removed 
in  forty-eight  hours,  and  the  other  on  the  fourth  day.  It  was  found  that  the 
wire  was  easily  applied,  as  easily  withdrawn,  and  entirely  effectual  for  the  pur- 
pose it  was  intended  to  serve,  namely,  the  arrest  of  the  bleeding  from  the  cut 
vessels.  This  patient,  being  the  subject  of  constitutional  syphilis,  did  badly. 
There  was  sloughing  of  the  entire  surface  of  the  wound,  and  the  flap  was  totally 
destroyed,  notwithstanding  which  there  was  no  hemorrhage ;  but  she  died,  on 
the  thirteenth  day  after  the  operation,  of  pyaemia.  Case  3  (September  21, 
1861).  In  an  amputation  of  the  thigh,  done  after  Mr.  Luke's  method,  there 
were  seven  bleeding  arteries.  Upon  five  of  these  the  wire  was  used,  and,  with 
the  femoral  artery,  the  femoral  vein  was  intentionally  included;  two  very  small 
branches  were  treated  by  torsion.  This  case  did  well.  Seventy-two  hours  after 
the  operation,  four  of  the  presse  artere  wires  were  withdrawn  with  perfect  ease 
and  without  bleeding.  The  one  on  the  femoral  remained  five  days,  when  it,  too, 
was  removed  without  any  difficulty  and  without  a  trace  of  blood.  There  was 
but  little  suppuration,  and  an  excellent  stump  was  the  ultimate  result.  These 


1863.] 


Surgery. 


501 


cases  prove  that  this  mode  of  securing  arteries  is  practicable,  efficient,  safe,  and 
manageable.  It  is  also  believed  to  possess  a  certain  positive  superiority  over 
the  ligature,  as  the  following  comparison  shows :  A  ligature  in  a  wound  impedes 
union  and  induces  suppuration.  Cure,  by  primary  adhesion,  of  a  large  wound, 
as,  for  instance,  an  amputation,  is  an  event  of  extreme  rarity,  and  this  because 
of  the  ligatures.  A  thread  of  silk  is,  in  fact,  a  miniature  seton,  and  the  whole 
number  required  in  an  operation  make  up  one  of  considerable  size,  and  can 
scarcely  fail  to  lead  to  the  formation  of  pus.  Again,  the  ligature  of  necessity 
excites  ulceration  of  the  artery  upon  which  it  is  tied;  it  cannot  in  any  other 
way  be  got  rid  of.  This  is  another  unhealthy  process,  antagonistic  of  repair. 
In  applying  a  ligature,  the  end  of  the  artery  is  drawn  out  from  its  sheath,  by 
which  its  natural  connections  are  disturbed,  and  its  vasa  vasorum  broken  up ; 
its  coats  also  are  lacerated  and  bruised.  The  ligature  remains  for  an  indefinite 
time,  long  after  it  is  useful  or  necessary,  and  it  is  not  unfrequently  pulled  at  by 
the  dresser  before  it  has  become  detached.  Its  knot,  often  deeply  buried 
between  the  flaps,  cannot  be  withdrawn  without  tearing  through  adhesions,  or 
damaging  the  granulations.  All  these  are  serious  obstacles  to  the  healing  pro- 
cess both  in  the  stump  and  in  the  artery  itself,  and  must  protract  the  period  of 
cure.  Moreover,  the  following  is  an  interesting  and  noteworthy  formula: 
Pyaemia  is  the  offspring  of  purulent  secretion,  of  which  the  ligature  is  an  efficient 
and  probable  cause.  Bleeding  arises  solely  from  ulceration  of  an  artery,  of  which 
again  the  primum  mobile  is  the  ligature.  From  one  and  all  of  these  objections 
to  the  ligature  the  "wire  compress"  is  almost  or  altogether  free.  Thus,  in  ac- 
cordance with  a  well-known  pathological  law,  it  being  a  metallic  substance,  is 
freely  tolerated  by  the  living  body,  and  has  little  or  no  tendency  to  excite  sup- 
puration or  irritation.  Neither  does  it  cause  ulceration  of  the  artery.  This  is 
positively  affirmed  from  actual  observation  of  its  effect  as  witnessed  in  the 
sloughing  stump  before  alluded  to.  It  is  applied  without  interference  with  the 
natural  relations  and  vital  connections  of  the  vessel.  It  is  removed  at  any 
time,  according  to  the  will  and  judgment  of  the  surgeon,  without  disturbance 
to  the  reparative  action  going  on  in  the  artery  and  in  the  rest  of  the  wound, 
without  futile  premature  attempts,  and  almost  without  pain  to  the  patient.  It 
is  not  liable  to  lose  its  hold,  or  to  become  detached  too  soon,  as  not  unfrequently 
happens  to  a  ligature  applied  upon  a  brittle  or  sloughing  artery.  Twigs  of 
nerve  accidentally  included  in  the  embrace  of  the  wire  are  not  injured  and 
excited  as  by  the  tight  strangulation  of  the  ligature,  and,  if  thought  advisable, 
the  veins  are  easily  and  safely  occluded,  along  with  the  arteries.  Although 
this  has  been  spoken  of  merely  as  a  modification  of  acupressure,  yet  it  is  be- 
lieved to  be  a  decided  and  important  improvement  on  "  Simpson's  skewers,"  as 
the  needles  have  been  irreverently  called,  and  which  are  fairly  open  to  the  fol- 
lowing objections :  When  several  of  them  are  required,  the  stump  resents,  as  it 
were,  being  thus  pierced  through  and  through  in  various  directions.  From  the 
injury  thus  inflicted,  and  from  the  obstruction  to  the  capillary  circulation 
caused  by  the  pressure  of  the  unyielding  steel,  arise  much  tension,  cedematous 
swelling,  and  great  pain ;  the  pain,  especially,  has  been  found  a  very  serious 
evil.  Again,  their  projecting  ends,  and  the  puckering  they  cause  in  the  sub- 
stance of  the  flaps,  interfere  very  much  with  that  accurate  adjustment  of  the 
cut  surfaces  and  edges  which  so  greatly  aids  the  chances  of  union  by  adhe- 
sion. The  wire  is  free  from  all  these  shortcomings.  It  is  thus  applied  :  Take 
a  piece  of  surgical  wire  six  or  eight  inches  long,  and  thread  each  end  thereof 
upon  a  straight  needle.  Seize  the  bleeding  mouth  of  the  artery  with  forceps, 
and  pass  one  of  the  aforesaid  needles  close  on  each  end  of  the  artery  just  men- 
tioned, about  a  line  above  the  point  of  the  forceps,  directly  down  through  the 
substance  of  the  flaps,  so  that  they  emerge  at  the  cuticular  surface,  about  half 
an  inch  distant  from  each  other.  Draw  them  both  through  together  till  the 
curve  of  the  wire  compresses  the  artery  on  the  face  of  the  flap.  Now  get  rid 
of  the  needles  by  clipping  through  the  wire  close  above  their  eyes,  and  also 
detach  the  artery  forceps.  Place  a  piece  of  cork,  cut  for  the  occasion,  upon 
the  skin,  between  the  points  of  exit  of  the  wire,  and  over  this  twist  the  wire 
tighter  and  tighter  until  the  bleeding  is  arrested.  Lastly,  cut  off  the  superfluous 
wire.    All  which  is  done  quicker  than  described.    Two  or  more  arteries  lying 


502 


Progress  of  the  Medical  Sciences. 


[April 


near  together  may  be  embraced  by  one  wire,  and,  as  has  been  said,  the  veins 
may  be  included  or  excluded  at  will.  The  wire  should  be  either  of  silver,  or, 
what  is  much  cheaper  and  equally  manageable,  of  the  finest  and  softest  passive 
iron.  The  generality  of  wire  as  used  for  sutures  is  too  hard  and  stiff.  The 
needles  are  about  three  inches  in  length,  straight,  and  three-edged,  with  an  eye 
adapted  for  carrying  wire.  Special  care  is  necessary  in  threading  the  wire  that 
it  is  kept  perfectly  free  from  all  twisting.  The  forceps  are  used,  not  to  draw 
out  the  artery  as  when  a  ligature  has  to  be  applied  (this,  indeed,  is  to  be  par- 
ticularly avoided),  but  merely  as  a  guide  to  mark  the  exact  position  and  course 
of  the  vessel.  The  cork  is  necessary  to  protect  the  skin  from  the  pressure  of 
the  wire.  The  withdrawal  of  the  wire,  which  at  first  sight  appears  an  insuper- 
able difficulty,  is  perfectly  simple  and  easy.  It  is  thus  effected:  Clip  the  wire 
close  to  the  edge  of  the  piece  of  cork,  and  straighten  out  the  curve  it  has  formed, 
at  its  exit  from  the  skin.  Remove  the  cork,  and  apply  instead  the  tip  of  one 
finger,  with  which  press  firmly  upon  the  flap,  making  traction  gently  and  gradu- 
ally upon  the  other  end  of  the  wire.  If  this  were  roughly  and  hastily  done,  it 
might  break  up  the  adhesion  which  it  is  presumed  has  taken  place  between  the 
surfaces  of  the  flaps,  and  it  is  quite  possible  that  a  flexure  in  the  wire  might 
lacerate  the  artery  in  passing  over  it ;  but  it  is  certain  that  none  of  these  evils 
need  happen  with  ordinary  care  and  tact.  As  to  the  period  of  withdrawal,  fur- 
ther observations  are  desirable ;  but  it  has  been  clearly  shown  in  numerous 
cases  of  acupressure,  that  for  small  vessels  a  few  hours  of  compression  is  suffi- 
cient, and  for  the  largest  arteries  a  much  less  time  than  might  be  supposed. 
However,  as  a  general  rule,  it  is  not  desirable  to  disturb  a  wound  in  any  way 
for  from  twenty-four  to  forty-eight  hours ;  at  the  end  of  which  time  all  wires 
commanding  the  secondary  branches  may  be  safely  removed,  and  probably  also 
from  the  large  arteries;  but,  as  a  matter  of  prudence,  it  is  well  to  keep  a  check 
upon  such  a  one  as  the  femoral  for  three  or  four  days  at  least.  The  descriptions 
hitherto  given  apply  particularly  to  amputations ;  but  the  wire  is  equally  appli- 
cable to  many  other  operations.  In  a  postscript  to  this  paper  was  related  a 
case  of  excision  of  the  testicle,  in  which  it  was  used  most  satisfactorily  upon 
the  vessels  of  the  cord.  Two  wires  were  required,  and  they  were  removed  on 
the  fourth  day.  Also  a  case  of  excision  of  the  breast,  in  which  three  wires  were 
applied,  and  removed  in  twenty-four  hours.  The  wound,  which  was  six  inches 
long,  healed  kindly  and  rapidly,  almost  without  suppuration.  Suppose  the  femoral 
artery  needs  to  be  secured  for  popliteal  aneurism.  The  wire  would  be  passed 
under  the  artery  by  means  of  a  tubular  aneurism-needle  made  for  the  purpose, 
brought  out  through  the  integument  at  a  convenient  situation,  and  then  twisted 
upon  a  cork  in  the  usual  way.  This  same  artery,  cut  in  amputation,  is  securely 
closed  in  three  or  four  days  by  the  action  of  metallic  pressure ;  consequently,  in 
three  or  four  days  the  wire  might  be  removed.  Meanwhile,  it  has  not  caused 
suppuration,  or  impeded  the  union  of  the  wound,  which  ought,  therefore,  by 
this  time,  to  be  completely  healed;  and  more  important  still,  the  artery  is  not 
cut  through,  as  by  the  ligature,  but  its  coats  remain  intact,  and  bleeding  is 
impossible.  It  will  probably  be  found  that  the  pedicle  in  ovariotomy  may  be 
conveniently  dealt  with  by  this  method,  the  arteries  being  secured  individually, 
and  the  entire  stump  also  fixed  to  the  abdominal  wall  by  another  wire.  This 
idea  has  been  already  promulgated  by  Mr.  Spencer  Wells.  The  paper  was 
illustrated  by  models. 

Mr.  Fkrgusson  said  that  the  author's  paper  ought  not  to  pass  without  remark, 
as  the  subject  was  novel  to  the  Society,  though  not  new  to  the  surgical  depart- 
ment of  the  profession.  The  paper  (he  said)  was  very  interesting  and  very 
clever,  and  yet  the  materials  of  it  were  not  sufficient  to  prove  the  author's 
point,  as  five  cases  only  were  reported.  These,  if  the  subject  had  been  quite 
new,  might  have  been  brought  forward.  From  the  cases  adduced,  he  had  not 
learned  that  there  was,  in  the  smallest  degree,  any  advantage  over  the  ligature, 
which,  as  a  practical  surgeon,  he  was  not  disposed  to  set  aside.  It  had  been 
brought  forward  by  a  gentleman  of  great  talents,  but  he  (Mr.  Fergusson)  had 
not  seen,  or  heard,  nor  found  anything  to  induce  him  to  imagine  this  process 
superior  to  the  ligature.  The  cases  related  were  very  few,  whilst  ten  times  that 
number  of  the  employment  of  other  means  might  be  brought  forward.  As 


1863.] 


Surgery. 


503 


regards  the  amputation  of  the  finger,  every  one  knew  that  such  eases  would  do 
perfectly  well  with  the  ligature.  In  the  case  of  partial  amputation  of  the  foot, 
he  did  not  suppose  that  the  sloughing  was  due  to  the  wire ;  but  the  fact,  that 
there  was  no  hemorrhage,  did  not  prove  that  the  wire  was  better  than  the 
ordinary  method  of  securing  bleeding  vessels.  As  to  the  plan  adopted  with 
regard  to  the  thigh,  that  was  not  new.  Professor  Handyside  had  tried  this 
method.  The  history  of  the  case  did  not  vary  from  the  ordinary  run  of  such 
amputations.  He  had  tried  this  plan  repeatedly,  but  should  require  much 
greater  proof  of  its  value  than  he  had  yet  heard  before  he  should  attempt  to 
secure  large  arteries,  as  the  femoral  or  the  brachial,  on  this  plan.  He  noticed 
that  in  this  paper,  as  also  in  many  others  on  the  same  subject,  there  was  a  con- 
stant attempt  to  decry  the  ligature,  one  of  the  grandest  things  in  surgery. 
Great  pains  had  been  taken  to  test  the  value  of  the  ligature,  and  he  thought 
that  the  question  had  been  set  at  rest.  One  point  urged  against  it  was,  that  it 
gave  rise  to  suppuration,  and  thus  favoured  pyaemia.  Of  this  he  was  doubtful, 
as  he  had  often  observed  that  patients,  after  operation,  had  feverish  symptoms 
which  gave  rise  to  great  anxiety,  but  which  passed  off  as  soon  as  suppuration 
set  in.  In  fact,  he  always  calculated  on  suppuration  as  a  relief  to  the  patient. 
He  thought  that  the  ligatures  acted  as  vents  for  the  discharge  of  pus;  and, 
as  regards  their  preventing  healing  by  first  intention,  he  would  say  that  the 
advantages  of  this  kind  of  union  were  overrated.  Suppose  the  stump  did  heal 
by  first  intention,  it  could  not  be  used  for  weeks — for  months,  as  it  was,  in  a 
great  measure,  new  material,  which  would  not  bear  pressure.  In  fact,  the  liga- 
tures were  of  advantage  in  this  way,  that  they  prevented  the  patient  using  his 
limb  too  soon. 

Mr.  Dix  said  that  he  rose  with  much  diffidence,  and  especially  so  because  his 
reply  must  be  chiefly  directed  to  the  remarks  of  Mr.  Fergusson.  "  Of  course 
(he  said)  I  feel  myself  quite  unable  to  cope  in  surgical  discussion  with  so  great 
a  surgical  authority;  nevertheless,  it  is  somewhat  encouraging  to  find  that  such 
an  opponent,  though  uncompromising  and  inclined  to  be  severe,  finds  so  few  real 
and  substantial  objections  to  the  subject  of  my  paper.  His  lengthened  argu- 
ment amounts  simply  to  this,  that  he  is  content  with  the  ligature.  In  support 
of  this  position,  he  tells  us  that  he  thinks  it  a  matter  of  little  moment,  whether 
a  wound  heals  by  primary  union  or  by  suppuration.  In  fact,  of  the  two,  he 
seems  to  prefer  the  latter.  Sir,  I  have  come  a  considerable  distance  to  attend 
this  meeting,  and  I  certainly  shall  not  return  without  having  gained  a  new  idea. 
This  doctrine  is  altogether  novel  to  me.  It  is  utterly  subversive  of  all  I  was 
taught  as  a  student,  and  is  entirely  opposed  to  my  own  somewhat  extensive 
observation  and  experience.  I  think  it  will  find  but  few  supporters  in  this 
room,  or  amongst  the  profession  at  large.  We  have  been  told  that,  as  regards 
the  time  at  which  a  stump  becomes  useful,  little  is  gained  by  primary  union, 
and,  in  the  same  breath,  it  is  somewhat  inconsistently  stated  that  suppuration 
is  inevitable — that  an  amputation  cannot  be  healed  without  it.  This,  sir,  is  a 
fallacy.  Primary  union  is  rare,  no  doubt,  but  not  impossible.  I  have  seen  it 
myself,  and  others  have  here  and  there  met  with  an  isolated  case.  About  five 
years  ago  I  amputated  the  leg  just  below  the  knee.  In  this  case,  although 
ligatures  were  used,  there  was  never  a  trace  of  pus;  in  about  six  days  this  stump 
was  entirely  and  soundly  healed.  I  must  say  that  I  thought  this  a  very  good 
thing,  and,  with  all  deference  to  the  great  authority  in  opposition,  I  must  still 
retain  my  humble  opinion,  that  it  is  far  better  than  a  suppurating  stump.  I 
am  fully  persuaded  that  the  chief  reason  why  this  good  result  does  not  oftener 
occur  is,  that  th^e  surgeons  who  doubt  its  possibility  do  not  adopt  the  best 
means  to  favour  its  occurrence.  He  who  hopes  most  and  attempts  most  will 
attain  most,  and  I  have  given  reasons  for  believing^ that  there  is  no  surer  step 
in  this  direction  than  the  disuse  of  the  ligature.  Pyaemia,  we  have  also  been 
told,  is  not  necessarily  connected  with  the  presence  of  pus.  This  may  be  so. 
It  may  be  that  there  is  such  a  disease  as  idiopathic  pyaemia,  but  it  is  a  doubtful 
point  and  difficult  of  proof.  A  far  more  certain  thing  it  is  that  pyaemia  can 
mostly  be  traced  to  a  pyogenic  source,  and  it  is  well  known  by  fatal  experience 
that  it  occurs  most  frequently  in  conjunction  with  an  unhealthy  suppurating 
stump.  Hence  I  have  argued  in  favour  of  endeavouring  to  prevent  or  to  lessen 


504  Progress  of  the  Medical  Sciences.  [April 

the  duration  of  suppuration.  My  cases,  I  grant,  are  few,  because  my  opportu- 
nities are  not  frequent,  but  I  may  claim  for  them  that  they  have  been  carefully 
and  anxiously  worked  out  under  considerable  difficulties  and  with  a  weighty 
responsibility;  and  I  am  perfectly  convinced  that  they  afford  good  ground  for 
believing  that  this  little  device  is  likely  to  be  of  real  practical  utility,  or  I  should 
not  have  appeared  here  to-night.  But  I  plead  not  guilty  to  the  charge  of 
having  exaggerated  the  evils  of  the  ligature,  or  of  having  made  too  much  of  my 
own  cases.  I  have  expressly  and  emphatically  stated  that  I  have  as  yet 
obtained  no  better  results  than  might  have  been  obtained  by  the  use  of  liga- 
tures, though  I  hope  ere  long  to  do  so.  That  the  ligature  is  an  old  friend,  well- 
tried  and  trustworthy — has  been  successfully  used  for  years,  and  does  well 
enough — that  somewhat  similar  attempts  to  find  a  substitute  for  it  have  failed 
— belong  to  that  kind  of  reasoning  by  which  all  abuses  are  defended,  and  all 
attempts  at  improvement  are  ignored  and  abolished;  they  are  not  of  much 
weight  on  the  present  or  any  other  occasion.  Mr.  Barwell  also  seems  to  have 
a  friendly  leaning  towards  the  ligature;  but  his  dread  of  sloughing,  from  the 
strangulation  produced  by  the  wire  is,  I  can  assure  him,  purely  imaginary.  If 
he  will  try  the  experiment,  he  will  probably  be  surprised  to  find  how  little  pres- 
sure is  needed  to  stop  the  bleeding  from  even  a  large  artery.  The  needles  of 
Dr.  Simpson  do  produce  injurious  and  inconvenient  compression,  but  the  wire 
compress  does  not,  and  it  is  one  of  the  advantages  I  have  claimed  for  it  over 
the  needles.  I  have  fully  shown  that  it  is  safe,  and  effectual,  and  manageable ; 
and  T  have  no  doubt,  from  the  attention  which  has  been  given  to  my  humble 
efforts  to-night,  and  from  the  ventilation  which  the  subject  has  here  received, 
that  the  wire  compress  will  soon  be  put  to  the  proof  by  others  who  have  better 
and  more  frequent  opportunities  than  I  have;  it  may  be,  perchance,  to  the 
advancement  of  the  science  of  surgery,  and  to  the  benefit  of  suffering  humanity." 
— Med.  Times  and  Gaz.,  Jan.  24,  1863. 

37.  A  Symptom  of  Fracture  of  the  Base  of  the  Skull. — In  a  communication 
made  to  the  Surgical  Society  of  Paris,  M.  Dolbeau  has  called  attention  to  the 
presence  of  ecchymosis  of  the  pharynx  at  its  upper  part  as  a  sign  of  fracture  of 
the  base  of  the  skull.  In  a  case  admitted  into  the  Bicetre,  where  death  took 
place  twelve  days  after  the  receipt  of  the  injury,  the  patient  complained,  when 
sensible,  of  pain  in  swallowing.  On  examination  after  death,  the  base  of  the 
skull  was  found  fractured ;  and  there  was  infiltration  of  blood  behind  the 
pharynx,  from  the  occipital  bone  to  the  second  cervical  vertebra ;  the  mucous 
membrane  of  the  pharynx  was  also  evidently  ecchymosed.  In  two  other  cases 
in  which  the  symptoms  pointed  to  injury  of  the  base  of  the  skull — contusion  in 
one,  and  fracture  in  the  other — and  in  which  recovery  took  place,  pain  in  deglu- 
tition was  complained  of ;  and,  on  examination,  in  each  case  there  was  found  to 
be  ecchymosis  of  the  posterior  wall  of  the  pharynx.  The  portion  of  the  pharynx 
in  which  the  ecchymosis  occurs  is  rather  difficult  to  be  seen ;  it  is  limited  by 
the  bone  of  the  skull  above  and  the  velum  palati  below,  by  the  vertebral  column 
behind,  and  the  posterior  orifice  of  the  nares  in  front. — British  Med.  Journal, 
June  7,  18G3,  from  Presse  Mid.  Beige,  27  Avril,  1862. 

38.  Recovery  after  Transfixion  of  the  Thorax  by  an  Iron  Bar. — Dr.  C.  W. 
Hoyland,  Surgeon-Superintendent  of  the  British  Seamen's  Hospital,  Con- 
stantinople, relates  the  following  remarkable  case.  Macknesky  Leon,  aged  25, 
a  Pole,  was  employed  in  the  hold  of  the  Liverpool  steamship  Sicilian,  discharg- 
ing bar  iron  ;  and  while  he  was  in  a  stooping  position  preparing  to  sling  a  bundle 
for  hoisting  on  deck,  a  bar  from  the  one  preceding  slipped  from  the  slings,  and, 
descending  end  on,  pinned  lum  to  the  flooring  of  the  hold,  penetrating  the  wood 
to  the  extent  of  three  inches,  and  requiring  the  united  efforts  of  three  men  to 
extract  it.  The  bar  was  of  angular  iron,  an  inch  and  a  half  square,  and  about 
fifteen  feet  long.  The  wounds  were  dressed  by  the  captain,  who  simply  applied 
pledgets  of  lint,  steeped  in  compound  tincture  of  benzoin,  to  the  sites  of  injury 
anteriorly  and  posteriorly,  and  a  roller  round  the  chest.  It  was  reported  that 
considerable  hemorrhage  took  place  at  the  time.  On  reception  at  the  hospital 
about  an  hour  after  the  accident,  Mr.  Hoyland  found  the  patient  much 


1863.3 


Surgery. 


505 


depressed;  he  had  a  feeble,  quick  pulse,  and  some  dyspnoea;  no  cough.  The 
dressing's  were  not  disturbed.  Depression  gradually  subsided,  and  the  reaction 
was  moderate,  no  inflammatory  or  other  unpleasant  symptoms  following.  The 
patient  was  kept  in  a  large  ward,  with  the  windows  open  night  and  day ;  and 
cold  applications  of  a  strong  infusion  of  matico,  in  which  a  little  chlorate  of 
potash  was  dissolved,  were  employed.  He  did  not  micturate  for  the  first 
twenty-four  hours,  and  the  bladder  appeared  quite  empty.  The  bowels  did  not 
act  until  the  fourth  day,  although  castor  oil  and  injections  were  administered 
freely.  On  the  fourth  day  the  bowels  were  evacuated  freely  once,  and  the  kidneys 
acted  regularly.  On  the  fifth  day,  in  the  presence  of  Mr.  J.  Murphy,  surgeon 
of  Her  Majesty's  ship  Gannet,  Mr.  Hoyland  removed  the  dressings,  found  the 
wounds  discharging  freely  and  granulating  kindly.  The  same  treatment  was 
continued — viz.,  pledgets  saturated  as  above.  The  iron  had  entered  posteriorly 
between  the  ninth  and  tenth  rib,  on  the  left  side,  a  little  before  the  angle, 
traversing  the  thorax  in  an  upward  and  slightly  outward  direction,  and  coming 
out  anteriorly  between  the  fifth  and  sixth  ribs  about  an  inch  below,  and  slightly 
outwards  of  the  nipple.  There  was  only  slight  constitutional  disturbance  for 
the  first  few  days,  with  slight  cough,  but  no  dyspnoea.  This  yielded  to  the 
antiphlogistic  regimen  and  saline  draughts,  the  bowels  throughout  being  gently 
relaxed.  He  was  discharged  quite  well  on  the  8th  of  September. — British 
Med.  Journal,  Dec.  13,  1862. 

39.  Osteo-aneurism. — Dr.  E.  D.  Mapother  reported  to  the  Surgical  Society 
of  Ireland  (January  23,  1863)  the  following  example  of  this  infrequent  disease : 
The  subject  of  it  was  a  gentleman  aged  28,  who  had  a  tumour  upon  his  left 
leg,  which  he  attributed  to  an  injury  about  five  years  ago,  when  he  accidentally 
struck  the  limb  against  a  chair.  He  had  tried  blisters,  ointments,  and  other 
means  for  its  removal,  without  success.  It  had  progressed  at  a  much  more  rapid 
rate  for  the  month  before  I  saw  him.  It  was  situated  on  the  inner  surface  of 
the  left  tibia,  about  its  centre,  and  appeared  like  a  node,  save  that  it  was  larger 
and  more  prominent,  projecting  externally  to  the  size  of  a  large  walnut,  and,  as 
we  had  afterwards  reason  to  believe,  dipping  into  the  bone  for  an  equal  depth. 
The  skin  was  tightly  stretched  over  it,  but  was  not  at  all  discoloured.  It  had 
a  slight  degree  of  elasticity,  but  its  most  remarkable  features  were  a  well-marked 
thrill  or  fremissement,  and  a  distinct  expansive  pulsation,  which  latter  was 
demonstrated  by  placing  a  bit  of  paper  on  the  tumour  and  looking  at  it  en  pro- 
file. The  pulsating  mass  rose  up  suddenly  from  the  bone,  which  was  plane  and 
healthy  around  it.  A  slight  bruit  was  audible  with  the  stethoscope.  Pressure 
on  the  femoral  or  popliteal  arteries  did  not  remove  these  symptoms.  It  was 
occasionally  painful  and  tender.  His  general  health  was  admirable,  and  there 
was  no  sign  of  strumous,  syphilitic,  or  cancerous  cachexia.  As  I  stated  that 
some  operative  procedure  was  called  for,  the  family  wished  for  the  advice  of  Dr. 
Hutton,  to  whose  mature  judgment  the  successful  issue  of  the  case  is  mainly 
due.  We  determined  first  to  remove  the  skin  by  potassa  fusa,  and  this  was  done 
readily  and  rapidly  by  first  raising  the  cuticle  with  a  blister.  The  thrill,  pulsa- 
tion, and  bruit  were  now  found  more  evident,  and  the  bone  was  seen  to  form  a 
thin  cribriform  shell,  the  periosteum  still  covering  the  small  spots  where  it  had 
been  removed.  The  tumour  did  not  give  the  sensation  similar  to  that  experi- 
enced in  squeezing  parchment  or  egg-shell,  which  Chelius  considers  very  cha- 
racteristic. Eemembering  the  frequent  occurrence  of  phlebitis  when  the  veins 
of  bone  are  divided,  we  were  disinclined  to  remove  the  tumour  by  a  gouge  or 
other  cutting  instrument.  I  may  here  say  incidentally  that  I  have  always  re- 
garded the  ready  absorption  of  pus,  and  occurrence  of  phlebitis  consequent 
upon  injury  of  bone,  as  due  to  the  peculiar  anatomical  arrangement  of  its  veins. 
As  described  many  years  ago  by  Dr.  Benson  in  the  article  "Bone,"  in  Todd's 
Cyclopaedia,  these  veins  pass  through  osseous  canals,  to  the  sides  of  which  they 
closely  adhere,  so  that  they  cannot  close  on  their  contents.  Nor  can  they 
readily  become  occluded  by  lymph,  which  we  know  is  Nature's  expedient  for 
preventing  the  dispersion  of  emboli  or  pus-clots.  Their  ready  power  of  absorp- 
tion was  demonstrated  by  Oruveilhier's  well-known  experiment :  he  injected  mer- 


506  Progress  of  the  Medical  Sciences.  [April 


cury  into  the  medullary  cavity  of  the  tibia  of  a  dog,  and  found  it  almost  imme- 
diately after  deposited  in  the  liver.  The  fact  that  pressure  on  the  femoral  artery 
did  not  stop  the  pulsation,  convinced  us  of  the  inutility  of  pressure  in  this  case, 
although  so  successful  in  aneurism  affecting  the  larger  trunks.  Still  less  were 
we  willing  that  the  patient  should  lose  his  limb,  although  amputation  has  been 
the  result  of  nearly  every  reported  case. 

We  resolved  to  try  the  effect  of  actual  cautery,  and  having  chloroformized 
the  patient,  we  pressed  an  iron  button  of  the  diameter  of  a  shilling,  heated  to 
a  white  heat,  deep  into  the  tumour ;  a  good  deal  of  hemorrhage  followed,  but 
was  repressed  by  muriated  tincture  of  iron.  In  seven  days  the  slough  separated 
in  small  gritty  pieces,  and  there  was  disclosed  a  mass  of  hard  pulsating  substance 
of  the  shape  of  large  granulations,  but  of  a  pale  colour.  Seeing  that  it  was 
necessary  to  reapply  the  cautery,  we  did  it  this  time  with  a  sharp  conical  iron, 
which  was  thrust  five  times  into  the  tumour,  and  thus  it  burnt  its  way  for  an 
inch  and  a  half  from  the  surface  of  the  tibia.  In  ten  days  a  thick  and  somewhat 
conical  slough  came  away,  leaving  a  cavity  filled  with  small  healthy  granulations 
at  its  sides,  but  with  a  small  spot  of  rough  bone  at  the  bottom.  This  gradually 
became  covered  in,  and  the  ulcer  assumed  the  healthiest  character.  The  patient 
has  not  suffered  in  any  perceptible  degree  from  the  confinement  to  which  he 
was  necessarily  subjected.  I  have  warned  him  against  any  sudden  or  violent 
exertion  of  a  nature  which  would  tend  to  injure  the  arterial  system,  for  there  is 
no  doubt  that  in  some  individuals  a  proneness  to  aneurismal  disease  exists, 
almost  in  the  manner  of  a  diathesis. 

I  shall  conclude  this  brief  sketch  with  a  few  reflections  on  the  pathology  and 
treatment  of  this  interesting  affection.  In  the  first  place,  I  trust  that  my  case 
proves  that  osteo-aneurism  can  exist  without  any  malignant  character — a  fact 
which  has  been  all  but  denied  by  Mr.  Holmes  in  his  recently  published  System 
of  Surgery.  The  skin  and  areolar  tissue  are  very  frequently  the  seat  of  tumours 
composed  of  dilated  arteries  and  capillaries,  and  there  seems  no  valid  reason 
why  so  vascular  a  structure  as  bone  should  not  occasionally  suffer  a  similar 
condition.  These  aneurisms  by  anastomosis  in  the  skin  are  certainly  much  more 
frequently  congenital,  but  there  are  many  authentic  accounts  of  their  being 
developed  at  various  ages  after  birth.  The  tumour  I  have  described  closely 
resembled  aneurism  by  anastomosis  in  the  thrill  and  bruit  which  it  possessed, 
and  in  the  abundance  of  the  hemorrhage  which  occurred  from  it  when  partly 
destroyed  by  the  heated  iron.  In  many  reported  cases  where  the  part  was  re- 
moved by  amputation,  the  tumour,  when  injected  and  carefully  examined,  was 
found  to  consist  of  dilated,  tortuous,  and  freely  communicating  vessels,  identical 
with  those  which  form  the  bulk  of  the  cutaneous  affection,  and  forming  a  mass 
extremely  like  the  uterine  surface  of  the  placenta.  I  had  no  opportunity  of 
making  such  observations,  but  the  features  of  the  disease  convinced  me  of  its 
close  analogy  with  aneurism  by  anastomosis.  As  regards  the  relative  frequency 
of  the  disease  in  various  bones  and  in  the  sexes,  Crisp  informs  us  that  out  of  25 
cases,  13  were  situated  in  the  tibia,  and  19  occurred  in  men.  The  same  author 
affords  statistical  information  which  may  guide  us  in  forming  a  prognosis,  for 
out  of  these  25  cases,  19  were  fatal  either  after  operations,  or  where  the  case 
was  not  at  all  interfered  with.  Ligature  has  proved  remarkably  unsuccessful, 
and  nearly  all  surgical  writers  agree  that  amputation  alone  gives  the  patient  a 
chance  of  recovery;  if,  however,  no  recurrence  of  the  disease  takes  place  in 
the  instance  I  have  detailed,  I  think  it  shows  that  reliance  can  be  placed  in  the 
actual  cautery  to  remove  the  slighter  and  more  circumscribed  examples  of  osteo- 
aneurism  in  its  earlier  stages.  It  will  gratify  me  extremly  to  hear  the  comments 
of  any  member  on  the  subject. 

Dr.  Mapother  added  that  the  first  operation  was  performed  two  months  ago, 
and  the  second  ten  days  after  that.  The  tumour  was  now  quite  removed,  and 
the  ulcers  were  healed  completely. — Dublin  Free  Press,  Feb.  4,  1863. 

[It  is  to  be  hoped  that  Dr.  Mapother  will  watch  the  future  progress  of  this 
interesting  case,  and  communicate  it  to  the  profession.  The  cure  is  too  recent 
to  pronounce  it  permanent,  or  to  lead  to  the  conviction  of  the  innocent  nature 
of  the  disease.] 


1863.] 


Surgery. 


507 


40.  Amputation  at  the  Hip-Joint  for  Malignant  Disease  of  the  Thigh. — Mr. 
James  Spence  records  (Edinburgh  Medical  Journal,  January,  1863)  a  case  of 
malignant  disease  occupying  the  middle  and  lower  part  of  the  right  thigh  of  a 
girl  15  years  of  age,  in  which  he  amputated  at  the  hip-joint.  The  operation 
was  successful  so  far  as  for  the  present  at  least  to  snatch  the  patient  from  the 
brink  of  the  grave  and  restore  her  to  health,  but  it  is  yet  premature  to  say  that 
the  disease  may  not  hereafter  return  in  some  other  organ. 

Mr.  S.  makes  the  following  observations  on  amputation  for  malignant  disease, 
which  are  worthy  of  consideration  : — 

"The  mortality  which  attends  amputation  at  the  hip-joint,  and  which  has 
even  led  some  to  question  the  justifiableness  of  the  operation,  is  undoubtedly 
very  great ;  and  hence  considerable  interest  attaches  to  every  successful  case, 
the  circumstances  under  which  it  was  performed,  and  all  the  conditions  which 
may  have  a  bearing  upon  the  general  question  of  the  operation  in  similar  cases. 
According  to  the  latest  statistics  of  the  operation,  given  in  the  recent  edition 
of  Cooper's  Surgical  Dictionary,  we  find  that,  in  a  total  of  139  cases,  there  were 
91  fatal  results,  or  a  mortality  of  65.46.  Moreover,  when  we  know  that  in  several 
of  the  successful  cases  the  operation  was  performed  on  limbs  which  had  pre- 
viously undergone  partial  amputation,  and  where  consequently  the  shock  and 
disturbance  of  the  system  caused  by  the  sudden  removal  of  the  whole  lower 
extremity  was  wanting,  or  at  least  greatly  diminished,  it  seems  evident  that  the 
risks  of  this  formidable  operation  are  such  as  must  limit  its  performance  to 
cases  of  extreme  necessity. 

"In  cases  of  certain  severe  injuries  the  surgeon  may  be  forced  to  perform  it 
as  the  only  chance  of  saving,  or  at  least  prolonging  life,  and  alleviating  suffering, 
by  removing  the  shattered  limb.  In  cases  of  disease,  the  question  of  operation 
comes  before  us  under  a  somewhat  different  aspect,  for  the  amputation  may 
prove  more  speedily  fatal  than  the  disease  would  have  done  if  left  to  its  own 
course.  Hence,  to  warrant  its  performance,  the  disease  must  be  of  a  kind  that 
admits  no  other  remedy,  and  at  a  stage  when  the  whole  of  the  appreciable  dis- 
ease can  be  removed,  and  with  a  reasonable  hope  of  prolonging  life.  In  the 
case  which  forms  the  subject  of  the  present  remarks  we  have  a  good  example  of 
the  conditions  which  warrant  us  in  having  recourse  to  amputation  at  the  hip- 
joint.  The  girl  was  suffering  from  intense  pain,  her  appetite  was  almost  gone, 
and  her  strength  exhausted  by  the  pain  and  want  of  sleep  ;  her  pulse  was  quick 
and  irritable,  whilst  the  tumour  was  increasing  rapidly.  The  urgency  of  these 
symptoms  showed  the  necessity  of  operative  interference,  if  any  attempt  was  to 
be  made  to  relieve  her  sufferings  and  to  prolong  life,  even  for  a  short  time ; 
whilst  the  absence  of  glandular  enlargement,  either  in  the  groin  or  elsewhere, 
gave  hopes  that  the  lymphatic  system  was  as  yet  unaffected,  and  that,  with 
youth  on  her  side,  there  was  a  reasonable  hope  of  success  attending  the  opera- 
tion. On  the  other  hand,  if  it  were  delayed,  or  not  performed,  a  speedy  and 
painful  death  was  certain. 

"  The  disease  was  limited  as  far  as  malignant  disease  can  be  said  to  be  limited 
in  the  living  body,  where  the  circulation  of  the  fluids  prevents  positive  limitation 
to  any  special  part.  But,  practically,  surgeons  are  agreed,  from  experience, 
that  malignant  disease,  especially  its  medullary  form,  when  situated  in  an  ana- 
tomically limited  organ — as  the  testicle,  for  example,  where  it  is  invested  by  a 
dense  resisting  capsule — admits  of  more  thorough  removal  than  when  it  occurs 
aoiongst  muscles  or  other  soft  textures,  whose  structure  it  speedily  involves  in 
the  same  diseased  action,  without  any  definition  or  limitation.  In  the  present 
case  the  disease  had  evidently  commenced  in  the  interior  of,  and  was  still  appa- 
rently confined  to,  the  shaft  of  the  femur.  Thus  walled  in,  as  it  were,  by  the 
dense  fibrous  shell  of  the  bone,  or  by  the  strong  fibrous  periosteum  investing 
the  shaft  on  every  side,  and  closed  in  at  either  extremity  of  the  bone  by  the 
articular  cartilage  of  incrustation,  the  disease  presented  the  utmost  possible 
degree  of  anatomical  limitation,  and  so  presented  the  best  possible  chance  of 
complete  removal.  But  to  profit  fully  by  this  limitation  of  the  disease  it  was 
evidently  necessary  to  amputate  in  the  contiguity,  and  not  through  the  continuity 
of  the  affected  bone — a  rule  which  I  consider  of  paramount  importance  in  such 
cases.    Hence  the  reason  why  I  considered  amputation  through  the  trochanters 


508  Progress  op  the  Medical  Sciences.  [April 


inadmissible,  although  the  bone  seemed  unaffected ;  for,  in  many  cases  where 
no  perceptible  alteration  in  the  form  of  the  bone  can  be  detected,  the  disease 
will  be  found  to  be  infiltrated  into  the  cancellated  texture  even  of  the  neck  and 
head  of  the  bone  ;  and  there  need  be  the  less  hesitation  on  this  point,  as  I  believe 
that,  in  cases  of  malignant  tumours  of  the  femur,  amputation  through  the  tro- 
chanters is  attended  with  quite  as  much  danger  to  life  as  amputation  at  the 
hip-joint." 

There  are  two  in  Mr.  S.'s  case  to  which  he  calls  attention,  and  which  are  of 
interest.  The  first  of  these  is  "  the  mode  adopted  to  restrain  hemorrhage  during 
the  operation.  This  was  effected  by  compressing  the  abdominal  aorta  by  the 
tourniquet,  or  compressor,  proposed  by  Professor  Lister,  of  Glasgow,  and  which 
he  kindly  lent  me  for  the  occasion.  I  had  previously  ascertained  that,  from  the 
thin  condition  of  the  patient,  I  could  readily  arrest  the  circulation  by  manual 
pressure  on  the  lower  part  of  the  aorta,  but  an  equal,  unyielding  mechanical 
compression  is  safer,  and  hence  I  preferred  it ;  but,  as  it  was  a  trial,  I  guarded 
against  all  risk  from  the  anterior  vessels  by  intrusting  the  care  of  the  femoral 
artery  to  my  colleague,  Dr.  Watson.  The  result,  however,  showed  the  efficiency 
of  the  instrument,  as  it  completely  commanded  the  usually  uncontrollable  flow 
of  blood  from  the  branches  of  the  internal  iliac  distributed  to  the  posterior  flap ; 
and  avoidance  of  loss  of  blood  in  an  exhausted  patient  must  have  a  most  im- 
portant bearing  on  the  success  of  the  case.  How  far  such  compression  could 
be  trusted  to  entirely  in  a  strong  man,  or  in  the  case  of  a  very  fat  person,  with 
a  large  abdomen,  or  whether  it  might,  if  incautiously  applied,  lead  to  injury  to 
the  viscera  in  certain  conditions,  further  experience  can  only  reveal ;  but  cer- 
tainly in  this,  and  two  cases  in  which  it  was  used  by  Professor  Syme,  it  proved 
perfectly  effectual. 

"  The  other  point  of  the  operation  I  would  refer  to  was  the  necessity  which 
arose  for  applying  a  ligature  to  the  femoral  vein.  The  hemorrhage  from  this 
vein  continued  after  all  pressure  had  been  removed  from  the  groin  and  abdomen, 
and  as  temporary  pressure  of  its  orifice  and  other  means  failed  to  arrest  it,  and 
as  it  returned  whenever  the  pressure  was  removed,  I  found  it  absolutely  neces- 
sary to  tie  it.  I  have  frequently  seen  troublesome  bleeding  from  the  femoral 
vein  in  amputation  of  the  thigh,  but  in  general  it  stops  when  compression  is 
made  by  applying  the  flap  against  its  surface,  when  all  pressure  above  is  re- 
moved, and  the  stump  elevated,  but  here  these  means  prove  ineffectual,  or  per- 
haps, I  should  rather  say,  the  weak  condition  of  the  patient  rendered  it  necessary 
at  once  to  check  all  loss  of  blood.  I  confess  that  my  prejudices  against  tying 
veins  are  very  strong,  and  this  step  in  the  operation  made  me  uneasy  as  to  its 
effects ;  but  as  the  history  of  the  progress  of  the  case  shows,  my  fears  were 
groundless,  not  a  single  bad  symptom  having  followed  ligature  of  the  vein." 

41.  The  Urine  in  Diseases  of  the  Bones. — In  the  course  of  a  series  of  papers 
on  inflammation  of  the  bones,  Dr.  Lorinser  of  Vienna  gives  the  results  of  some 
observations  made  by  Professor  Kletzinsky  on  the  chemistry  of  the  urine  and 
pus  in  cases  of  inflammation  of  bone. 

In  very  acute  cases  of  inflammation  of  bone  the  urine  presents  marked  pecu- 
liarities. There  is  not  only,  as  ordinarily  occurs  in  inflammations,  a  diminution 
of  the  chlorides,  with  a  copious  or  increased  excretion  of  urea,  uric  acid,  ex- 
tractive matter,  and  alkaline  sulphates  and  phosphates,  but  the  phosphate  of 
lime  is  also  greatly  increased  in  quantity,  and  is  not  unfrequently  found  in  the 
urinary  sediments  in  the  form  of  bone-earth.  The  chlorides  diminish  from  their 
normal  proportion  (about  10  per  1000)  often  to  as  low  as  1  per  1000 ;  while  the 
earthy  phosphates  increase  from  3  to  10  parts  in  1000,  or  even  higher.  In  the 
further  progress  of  acute  ostitis,  the  chlorides  again  gradually  increase ;  the 
urea  and  the  urates  and  sulphates  also  diminish ;  but  the  proportion  of  the 
phosphates  varies  according  as  the  disease  is  unattended  with  suppuration  or 
any  remarkable  amount  of  osteophytic  growth,  or  with  necrosis  and  the  forma- 
tion of  new  bone.  In  cases  of  the  first  category — "  dry  inflammation  of  bone," 
as  it  is  sometimes  called — the  phosphates,  and  especially  the  phosphate  of  lime, 
remain  at  a  high  figure  until  the  inflammation  ceases ;  and  the  latter  often 
appear  excreted  in  the  form  of  amorphous  bone-earth.   If  necrosis,  with  suppu- 


1863.] 


Surgery. 


509 


ration  and  subsequent  formation  of  new  bone  set  in,  there  is  a  diminution  in  the 
quantity  of  the  phosphates,  and  especially  the  phosphate  of  lime,  which  is  em- 
ployed in  the  process  of  bone-growth. 

The  manifestations  of  the  phosphates  in  the  urine  correspond  perfectly  with 
the  chemical  characters  of  the  diseased  bone. 

In  the  inflamed  bone  itself  (without  reference  to  new  osseous  growths)  there 
is  always  a  very  marked  diminution  of  the  bone-earth,  which,  during  the  exu- 
dation-stage of  the  inflammation,  is  rapidly  absorbed  and  carried  away  by  the 
urine.  The  proportion  of  water  in  the  bone  is  at  the  same  time  increased,  and 
the  animal  matter  is  diminished.  The  normal  proportion  of  carbonates  to  phos- 
phates in  the  ashes  of  bone  is  destroyed,  while  that  of  magnesia  to  lime  remains 
undisturbed.  Albumen  and  chloride  of  sodium,  which  are  scarcely  to  be  found 
in  healthy  bones,  are  generally  greatly  increased  in  quantity;  and  tyrosin  can 
also  for  the  most  part  be  detected. 

As  soon  as  new  bone  begins  to  be  deposited,  the  excess  of  phosphate  of  lime 
in  the  system  is  used  in  its  formation ;  and  consequently  there  is  a  diminution 
in  the  excretion  of  the  phosphates,  especially  the  earthy  phosphates,  by  the 
urine.  The  bony  deposit  does  not  at  first  show  the  normal  condition  of  bone  ; 
but  the  "  glutin,"  and  especially  the  bone-earths,  are  far  more  abundant  than  in 
the  inflamed  and  necrosed  bone,  and  the  excess  of  water  is  diminished  ;  but  the 
newly  formed  bone  contains  decidedly  less  fat.  The  following  analysis,  taken 
from  a  patient  aged  29,  who  had  necrosis  after  acute  inflammation  of  the  tibia, 
shows  the  difference  in  the  composition : — 


Necrosed  bone. 

Newly  formed  bone. 

Water  

71.7 

'  32.8 

Fat  

2.4 

0.8 

"Glutin"  

12.3 

26.4 

Bone-earth  .... 

12.4 

40.0 

Other  organic  matters 

A  trace. 

100.0 

100.0 

In  both  instances  the  proportions  differ  from  those  of  normal  bone  ;  in  which 
the  amount  of  water  is  ordinarily  10,  of  "  glutin"  30,  and  bone-earth  60  per  cent. 

In  chronic  inflammation  of  bone,  the  changes  in  the  urine  presented  in  acute 
inflammation  are  not  perceived  ;  there  does  not  appear  to  be  a  notable  diminu- 
tion of  the  chlorides,  unless  a  sudden  attack  of  acute  inflammation  set  in.  But 
the  phosphates  are  increased  in  quantity  in  the  urine  as  in  acute  ostitis,  espe- 
cially the  earthy  phosphates.  If  at  a  later  stage  of  the  chronic  disease  an 
energetic  osteophytic  development  take  place,  or  especially  if  the  weakened 
osseous  tissue  be  again  thickened,  the  quantity  of  earthy  phosphates  in  the 
urine  is  diminished ;  but  if  none  of  this  reparative  reaction  occur,  the  quantity 
of  these  salts  goes  on  increasing.  Hence,  in  all  cases  of  chronic,  especially 
lingering,  inflammation  of  bones,  and  even  in  spinal  curvature,  knock-knee,  &c, 
the  examination  of  the  urine  affords  most  important  indications  as  to  the  stage 
of  the  disease — a  point  often  difficult  to  be  determined.  The  same  observation 
is  applicable  to  the  healing  of  fractures. 

In  long  standing  caries  the  earthy  phosphates  appear  abundantly  in  the  urine, 
mostly  in  company  with  some  albumen,  uroerythrin,  and  carbonate  of  ammonia 
(produced  by  decomposition  of  urea),  and  even  tyrosin.  In  the  stage  of  greatest 
exhaustion,  the  phosphates,  with  the  urea  and  uric  acid  are  diminished,  and  the 
albumen  is  then  generally  accompanied  with  haematin. 

In  the  so-called  "phosphorus  necrosis"  (disease  of  lucifer-match  makers), 
phosphites  and  hypophosphites  appear  in  the  urine  ;  showing  that  the  disease  is 
certainly  not  local,  but  must  be  connected  with  important  changes  in  the  blood 
itself. 

A  rather  considerable  excretion  of  phosphates,  especially  alkaline  phosphates, 
takes  place  in  suppuration.  The  phosphates,  especially  at  the  commencement 
of  the  suppuration,  appear  very  abundant  in  the  pus  discharged  from  abscesses 
that  have  been  opened ;  and  they  retain  their  high  figure  through  the  continu- 
ance or  increase  of  the  destruction  of  the  bone  up  to  the  time  of  death.  Even 


510  Progress  op  the  Medical  Sciences.  [April 


during  extreme  exhaustion,  when  the  amount  of  phosphate  in  the  urine  is  dimi- 
nished, that  in  the  pus  is  increased.  The  proportion  of  alkaline  to  earthy  phos- 
phates, which  in  normal  pus  is  7  to  1,  often  varies  greatly  with  the  stage  and 
course  of  the  disease,  and  the  state  of  the  patient's  general  health.  In  phos- 
phorus necrosis,  the  alkaline  phosphates,  in  the  pus  first  discharged,  are  in- 
creased more  than  threefold  ;  the  pus  also  generally  contains  tyrosin  as  well  as 
phosphites  and  hypophosphites. 

In  chronic,  as  in  acute,  inflammation  of  bones,  there  is  an  increase  of  the 
water  and  a  diminution  of  the  animal  and  mineral  matters.  In  cases  of  long 
standing  caries,  with  extreme  exhaustion,  the  proportion  is  sometimes  changed; 
while  the  mineral  matters  continue  diminished,  the  animal  matter  is  increased, 
so  that  there  is  an  apparent  diminution  in  the  proportion  of  water,  which  is, 
nevertheless,  still  great.  Albumen,  which  is  almost  absent  in  healthy  bone, 
appears  in  abundance  in  chronic  inflammation,  especially  in  caries  of  long 
standing.  The  proportion  of  carbonates  to  phosphates,  which  in  normal  bone 
is  as  1  to  7.25,  varies  in  chronic  inflammation  of  bone  from  1  in  4  to  1  in  12.  In 
phosphorus  necrosis  there  is  not  so  great  a  deviation  from  the  proper  propor- 
tions of  water,  animal  matter,  and  mineral  matter,  as  in  other  forms  of  caries 
and  necrosis.  This,  however,  depends  on  whether  the  nutrition  of  the  bone  has 
or  has  not  been  suddenly  interrupted  by  the  phosphorus  necrosis.  In  the  former 
case  the  composition  of  the  bone  will  naturally  be  less  altered  than  in  the  latter. 
— British  Medical  Journal,  Dec.  6,  1862,  from  Wiener  Med.  Wochenschr.,  Oct. 
4,  1862. 

42.  Sac  of  a  Spina  Bifida-  successfully  removed  by  Operation. — Dr.  Wilson, 
of  Clay-cross,  sent  to  the  Pathological  Society  of  London  (Jan.  6,  1863)  this 
specimen.  The  child  from  whom  the  sac  was  taken  was  a  fine,  and,  in  other 
respects,  well-formed  boy,  the  first  child  of  young  parents.  The  tumour  was 
pyriform,  the  size  and  shape  of  a  ten-ounce  necked  cupping  glass.  It  hung 
from  the  upper  dorsal  region  of  the  spine,  was  flaccid,  and  only  partly  filled 
with  fluid;  the  integuments  over  it  were  very  thin,  indeed,  translucent,  and  over 
the  most  prominent  part  of  the  swelling  were  two  small  excoriations.  At  the 
base  of  the  tumour  could  be  felt  a  deficiency  in  the  bones  beneath,  correspond- 
ing with  the  third  and  fourth  dorsal  vertebrae.  There  was  no  paralysis  or  other 
symptom  of  deficiency  of  nervous  power.  From  the  time  of  birth  Dr.  Wilson 
applied  pressure  to  the  base  of  the  tumour,  so  as  to  isolate  it  from  the  spinal 
canal  as  far  as  possible.  To  relieve  the  tension  of  the  integuments  which  had 
become  extreme,  on  the  twentieth  day  after  birth  it  was  punctured,  and  eight 
ounces  of  fluid  were  drawn  off.  During  the  next  twelve  days  it  was  tapped 
four  times,  each  time  about  two  ounces  of  fluid  being  drawn  off.  A  steel  clamp 
was  applied  to  the  base  for  five  days  before  removal,  and,  on  the  thirty-third 
day,  the  sac  and  integuments  were  shaved  off  at  the  base  of  the  tumour,  which 
was  grasped  by  a  pair  of  circumcision  forceps.  The  cut  edges  of  the  spinal 
membrane  were  lightly  touched  with  a  red-hot  needle,  sutures  were  applied  to 
the  wound,  and  pressure  to  the  base  of  the  tumour.  Twenty  days  after  the 
operation  the  wound  had  entirely  healed.  Two  months  after  the  operation  the 
chink  in  the  vertebrae  was  found  to  be  closed  by  a  solid  mass  which  projected 
somewhat  beyond  the  neighbouring  spines,  and  appeared  to  be  formed  of  bone. 
The  sac,  as  Dr.  Wilson  says,  consists  of  thin  integuments  covering  the  dura 
mater,  to  which  it  is  unadherent;  this  is  lined  internally  by  a  layer  of  epithe- 
lium resting  on  a  basement  membrane,  coated  on  its  free  surface  by  a  more  or 
less  organized  exudation  of  lymph.  The  dura  mater  is  quite  an  independent 
coat  in  this  tumour,  and  is  in  no  way  connected  with  the  integuments:  the  sac 
contains  no  nerves.  The  fluid  in  this  case  was  situated  in  the  sac  of  the  arach- 
noid, and  not,  as  is  usually  the  case,  in  the  sub-archanoid  space.  The  tumour 
(Mr.  Smith  said)  had  been  examined  by  Dr.  Cornelius  Black,  of  Chesterfield, 
by  Mr.  Savory,  and  by  himself,  and  all  coincided  with  Dr.  Wilson  in  his  account 
of  its  structure  and  connections  with  the  spinal  membranes. 

Mr.  Hutchinson  remarked  that  this  case  had  been  very  correctly  described 
as  the  first  successful  one  of  its  kind  in  English  practice.  It  was  not,  however, 
by  very  far  the  first  in  which  a  similar  plan  had  been  tried.    All  the  others  had 


1863.] 


Surgery. 


511 


ended  fatally,  and  he  (Mr.  Hutchinson)  found  in  this  fact  a  very  strong  argu- 
ment against  the  measure.  We  must  not  be  misled,  by  the  successful  result  of 
a  single  case,  into  adopting  a  practice  which,  in  the  long  run,  would  destroy 
many  lives.  He  gave  a  strong  opinion  against  all  operative  interference  with 
spina  bifida,  stating  that  he  had  witnessed  many  operations  of  very  various 
kinds  for  the  cure  of  this  deformity,  but  every  one  of  them  had  been  followed 
by  the  same  result.  In  several  of  these  there  was  every  probability  that,  had 
the  operation  not  been  performed,  the  patient  might  have  grown  up.  He  had 
seen  several  adult  patients  the  subjects  of  spina  bifida  which  had  been  wisely 
let  alone  in  infancy. — Med.  Times  and  Gaz.,  Jan.  31,  1863. 

43.  Ovariotomy. — Mr.  Yeo  read  before  the  Junior  Medical  Society  a  paper  on 
this  operation.  He  commenced  by  observing  that  the  subject  was  so  mature, 
and  surrounded  by  so  many  well-authenticated  facts,  that  it  might  fairly  be  dis- 
cussed by  this  Society.  In  doing  so  it  was  desirable  to  be  influenced  not  so 
much  by  the  weight  of  authority,  but  rather  by  a  calm  review  of  the  facts  of  the 
case,  and  the  reasonable  inferences  to  be  deduced  therefrom.  The  history  of 
the  operation  was  then  traced,  from  its  origin  in  America,  in  1809,  and  its  inaus- 
picious introduction  into  Great  Britain  by  Mr.  Lizars  in  1823,  to  its  re-introduc- 
tion by  Dr.  Clay  in  1842,  and  its  subsequent  steady  progress.  He  then  enume- 
rated the  various  other  means  that  had  been  suggested  for  dealing  with  ovarian 
tumours,  and  alluded  to  their  generally  unsatisfactory  results  ;  and  after  sketching 
the  usual  course  of  a  case  of  ovarian  disease,  if  left  to  itself,  or  merely  submitted 
to  palliative  treatment,  he  passed  on  to  the  consideration  of  the  operation  of 
ovariotomy  itself,  pointed  out  the  cases  in  which  it  appeared  justifiable,  and 
thought  it  should  be  restricted  to  those  cases  where  the  disease  manifested  a 
progressively  fatal  tendency,  or  where  the  patient's  life  was  rendered  so  miser- 
able that  an  operation  was  eagerly  sought  after.  While  alluding  to  the  modes 
of  performing  the  operation  and  the  proper  after-treatment,  the  author  men- 
tioned the  particulars  of  two  recent  cases,  one  in  which  Mr.  Fergusson,  and  the 
other  in  which  Mr.  Bryant,  had  operated.  He  then  stated  the  common  objec- 
tions to  the  operation,  and  thought  they  would  be  removed  by  the  results  of  an 
extended  experience,  a  careful  selection  of  cases,  and  a  careful  observation  in 
operation  of  all  the  details  that  the  most  experienced  in  these  cases  had  sug- 
gested and  found  necessary ;  observing,  in  conclusion,  that  after,  and  in  spite 
of,  much  opposition,  ovariotomy  might  now  be  regarded  as  about  to  take  its 
place  amongst  the  greatest  achievements  of  the  progressive  surgery  of  the  nine- 
teenth century. — Lancet,  Dec.  27,  1862. 

44.  Imperforate  Anus;  Successful  Treatment  by  Perineal  Incision. — One 
of  the  operations  for  the  remedy  of  artificial  anus  in  children  consists  in  making 
an  incision  in  the  perineum,  detaching  the  rectum,  and  bringing  it  down  and 
fixing  it  to  the  external  wound,  so  as  to  make  a  new  anus.  An  operation  of 
this  kind  is  reported  by  Dr.  Friedberg,  of  Berlin,  as  having  been  performed  by 
him  with  success.  The  patient  was  a  male  child.  The  medical  man  in  attend- 
ance had  incised  the  perineum  and  opened  the  rectum,  with  relief  for  a  time ; 
but  defecation  became  gradually  more  difficult,  and  ceased  when  the  child  was 
about  nine  weeks  old.  Dr.  Friedberg  was  now  called,  and  operated  in  the  man- 
ner above  described.  The  stools  were  passed  daily  for  three  months.  At  this 
time,  constipation  set  in.  The  passage  was  found  to  be  perfectly  free  ;  and  the 
constipation  was  relieved  by  drawing  away  an  accumulation  of  scybala  about 
four  inches  above  the  anus.  The  newly  formed  anus  had  at  this  time  all  the 
appearance  of  the  natural  opening,  and  contracted  on  the  finger. — Ibid.,  from 
Arch,  fur  Path.  Anat.,  and  U  Union  MSd.,  1  Avril,  1862. 

45.  Vaginal  Lithotomy. — Dr.  Aveling,  of  Sheffield,  read  a  paper  on  this  ope- 
ration before  the  Obstetrical  Society  of  London  (Jan.  7,  1863).  The  author 
commenced  by  reciting  the  particulars  of  thirty-five  cases  in  which  this  opera- 
tion had  been  performed — twelve  British,  and  twenty-two  foreign.  The  author 
also  gave  another  case,  in  which  he  divided  the  vesico-vaginal  septum,  and  ex- 
tracted a  small  rough  stone.    The  wound  was  brought  together  with  silver  wire 


512 


Progress  of  the  Medical  Sciences.  [April 


sutures.  Gilt  beads  were  passed  over  the  ends  of  these,  and  run  down  to  the 
lips  of  the  wound.  These  were  kept  in  position  by  a  perforated  shot,  also  passed 
over  the  ends  of  the  sutures,  and  tightened  upon  them  by  a  pair  of  forceps. 
He  proposes  in  future  to  use  a  coil,  made  by  winding  a  piece  of  the  suture  wire 
round  a  pin,  instead  of  the  beads.  The  wound  healed  in  a  week,  and  the  patient 
returned  to  her  home  in  a  fortnight. 

Mr.  Spencer  Wells  congratulated  Dr.  Aveling  upon  the  successful  result  of 
his  interesting  case,  and  heartily  concurred  in  the  tribute  he  had  paid  to  the 
services  of  Dr.  Marion  Sims.  But  he  (Mr.  Wells)  had  begun  to  doubt  whether 
the  success  which  had  followed  the  operation  for  the  cure  of  vesico-vaginal  fis- 
tula of  late  years  was  so  much  due  to  the  use  of  wire  sutures  as  to  the  improve- 
ments which  Dr.  Sims  had  originated  in  the  mode  of  bringing  the  fistula  into 
view,  accurately  paring  the  edges,  and  bringing  them  into  perfect  apposition. 
Provided  the  edges  of  a  fistula  were  thoroughly  pared,  and  kept  in  close  appo- 
sition, it  was  probably  of  little  importance  how  this  was  done.  A  year  ago  he 
(Mr.  Wells)  was  as  strongly  in  favour  of  metallic  sutures  as  anybody;  but 
latterly  a  wider  experience  had  taught  him  that  it  is  only  after  five  or  six  days 
that  wires  show  any  advantage  over  silk,  and  before  that  time  the  sutures  ought 
to  be  removed.  Then  silk  offers  the  great  advantages  over  wire  of  being  more 
easily  applied,  of  not  requiring  so  large  a  needle  to  pass  it,  of  the  ends  being 
much  less  irritating,  and  of  being  more  easily  removed.  After  many  compara- 
tive trials  on  different  parts  of  the  same  wound  with  wires  of  silver,  iron,  lead, 
platinum,  and  aluminium,  and  with  fine  catgut,  horsehair,  telegraph  wire,  India- 
rubber  thread,  and  the  fine  strong  silk  known  as  "  Chinese  twist, "lie  had  become 
convinced  that  wires  offered  no  advantage  over  silk,  while  silk  offered  many 
advantages  over  every  other  material  used  for  sutures.  In  a  recent  case  he  had 
closed  a  vesico-vaginal  fistula  by  five  silk  sutures,  and  perfect  union  resulted, 
although  no  catheter  was  used.  The  supposed  necessity  for  the  use  of  the 
catheter  after  closing  vaginal  fistulse,  was  another  error  which  time  was  cor- 
recting. The  urine  is  by  no  means  so  irritating  a  fluid  as  some  believe.  The 
lower  orders  use  it  as  a  lotion  to  the  eyes  and  to  sore  legs ;  and  it  certainly 
cannot  differ  much  from  the  dilute  saline  solutions  constantly  prescribed  as  as- 
tringents or  stimulants.  The  use  of  the  catheter  is  the  most  troublesome  part 
of  the  after  treatment,  and  often  most  distressing  to  the  patient.  One  of  his 
patients  really  could  not  bear  it,  yet  she  did  perfectly  well;  and  lately  he  had 
not  used  it  at  all,  union  taking  place  quite  as  well  as  when  it  was  used,  and  the 
patient  being  much  more  comfortable.  With  regard  to  stone  in  the  bladder 
during  labour  being  a  cause  of  vesico-vaginal  fistula,  he  had  once  removed  in 
the  Samaritan  Hospital  a  large  stone  through  a  fistula  before  closing  it ;  but 
it  was  very  questionable  whether  it  could  often  be  necessary  to  remove  a  cal- 
culus through  the  vagina  when  no  fistula  existed,  or  to  run  the  risk  of  making 
a  fistula  to  remove  a  stone.  Lithotrity  was  very  easily  performed  in  women ; 
and  large  fragments  of  stone  passed  readily  through  the  short  female  urethra, 
so  that  no  form  of  lithotomy  could  often  be  called  for.  Simple  dilatation  of  the 
urethra  was  not  likely  to  answer  in  any  case  not  suitable  for  lithotrity,  and  its 
effects  are  very  uncertain  :  a  large  stone  might  be  removed  and  no  incontinence 
follow ;  but  incontinence  might  follow  removal  of  a  very  small  calculus.  The 
usual  aid  to  dilatation  by  incising  the  urethra  was  still  worse.  A  surgeon  of 
very  large  experience  had  told  him  ttiat  he  had  done  it  for  two  adults  and  seven 
children,  and  "they  were  all  dribblers."  Where,  from  some  exceptional  condi- 
tion of  bladder  or  stone,  lithotrity  was  inappropriate,  vaginal  lithotomy  might, 
therefore,  become  a  valuable  operation ;  but  experience  was  still  wanting  to 
show  that  it  was  better  than,  or  as  good  as,  the  lateral  operation  so  successfully 
practised  by  Dr.  Buchanan,  of  Glasgow.  The  subject  was  a  comparatively 
new  one.  and  Dr.  Aveling  deserved  the  thanks  of  the  profession  for  the  light 
he  had  thrown  upon  it. — Med.  Times  and  Gaz.,  Feb.  7,  1863. 


i 

1863.]  Midwifery.  513 


MIDWIFERY. 

46.  Tartrate  of  Antimony  as  an  Oxytoxic. — Dr.  Parker  communicated  to 
the  Obstetrical  Society  of  Edinburgh,  the  following  notes :  Tartarized  anti- 
mony has  long  been,  as  you  are  aware,  in  use  in  obstetric  practice.  Lecturers 
and  authors  have  informed  us,  and  still  continue  to  do  so,  that  the  result  of  its 
administration  is  to  advance  the  labour — 1st  By  overcoming  muscular  rigidity ; 
2d.  By  causing  a  free  flow  of  mucus,  and  thus  lubricating  the  vaginal  mucous 
membrane.  While  not  confining  its  use  to  primiparse,  they  speak  of  it  as  more 
especially  serviceable  in  this  class  of  cases. 

With  this  much  theoretic  knowledge  of  its  action  I,  sixteen  years  since,  com- 
menced testing  it  practically,  and  it  was  not  long  before  I  observed  that,  in 
addition  to  the  actions  previously  attributed  to  it,  a  very  important  end  was 
effected  in  a  large  majority  of  cases  by  its  administration.  I  refer  to  its  in- 
fluence on  the  uterine  contractions ;  in  other  words,  to  this  agent  as  a  powerful 
stimulant  to  the  involuntary  muscular  action  of  that  organ.  While  relaxing 
the  circular  or  sphincter  fibres  of  the  os  uteri,  I  observed  that  it  produced 
more  powerful  propulsive  efforts,  by  stimulating  the  longitudinal  and  other 
muscular  fibres  concerned  in  effecting  delivery. 

As  early  as  the  years  1846  or  1847  I  called  the  attention  of  some  of  my  medi- 
cal friends  to  the  facts,  and  requested  them  to  keep  a  record  of  cases  in  which 
this  auxiliary  agent  was  prescribed. 

It  is  unnecessary  that  I  should  occupy  the  time  of  the  Society  by  detailing 
minutely  reports  from  my  case-book.  A  brief  summary  of  what  I  have  ob- 
served in  reference  to  this  matter  in  a  very  large  number  of  instances,  and  the 
deductions  drawn  therefrom  will  suffice,  and  equally  subserve  the  end  I  have  in 
view. 

1st.  Tartarized  antimony  relaxes  both  voluntary  and  involuntary  muscular 
fibre  concerned  in  resisting  and  retarding  labour ;  in  other  words,  it  overcomes 
the  rigidity  of  the  os  uteri  and  perineal  muscles. 

2d.  By  increasing  the  vaginal  mucous  flow,  and  lubricating  that  surface,  it* 
essentially  aids  the  progress  of  parturition. 

3d.  It  stimulates  to  increased  contractile  action  the  oblique,  longitudinal,  and 
other  muscular  fibres  concerned  in  expelling  the  child.  It  may  be  said  that 
this  increased  contractile  action  is  only  apparent,  and  that  the  advance  of  the 
labour  is  due  to  the  decreased  rigidity  and  resistance  of  the  os  and  more  exter- 
nal parts,  in  consequence  of  the  tartarized  antimony  having  produced  the  re- 
sults stated  in  the  two  preceding  propositions.  This  objection  is  at  once  re- 
moved and  proved  to  be  incorrect  by  the  results  following  its  administration,  in 
cases  not  primiparous,  where  there  is  "'inertia  uteri"  with  the  os  fully  dilated, 
the  vagina  patent,  and  the  perineum  not  rigid.  In  just  such  labours  I  have 
been  in  the  habit  of  prescribing  the  tartarized  antimony  instead  of  ergot,  with 
the  most  marked  results. 

4th.  Unlike  ergot  of  rye  it  does  not  produce  continuous  contractions,  but,  in 
the  majority  of  cases,  enhances  the  power  and  force  of  the  regular  pains,  and 
admits  an  interval  of  ease. 

5th.  It  continues  to  some  extent  to  exert  its  contractile  influence  after  the 
expulsion  of  the  child,  and  hence  reduces  the  risk  of  hemorrhage.  Of  course 
this  result  will  be  modified  by  the  interval  that  has  elapsed  between  the  admin- 
istration of  the  antimony  and  the  delivery. 

Qth.  Unlike  ergot,  it  does  not  interfere  with  the  extraction  of  the  placenta, 
by  producing  irregular  uterine  contractions.  The  superior  and  propelling  por- 
tion of  the  organ,  it  is  true,  is  generally  more  firmly  contracted  than  natural 
after  delivery ;  but  the  sphincter  (the  os)  is  mobile  and  yielding,  and  but  little 
difficulty  (no  morbid  condition  of  the  parts  being  present)  is  experienced  in  this 
particular;  abdominal  pressure,  and  traction  in  the  proper  axis  will  almost 
invariably  effect  the  end  without  injury  to  the  cord. 

1th.  While  perhaps  more  applicable  to  primiparee,  tartarized  antimony  may 
No.  XC.— April  1863.  33 


514  Progress  of  the  Medical  Sciences.  [April 


be  administered  with  like  results  in  subsequent  labours,  and  that  at  any  age  or 
stage  of  labour,  without  risk  of  injury  to  the  uterine  texture. 

8th.  Administered  as  I  shall  presently  state,  its  emetic  effects  are  not  trouble- 
some ;  not  more  so  when  they  do  occur  than  from  ergot,  when  this  latter,  as  it 
very  frequently  does,  produces  vomiting.  This  effect  of  the  antimony,  when 
present,  will  promptly  yield  to  cold  oatmeal,  coffee,  a  mustard  cataplasm  over 
the  stomach,  or  a  dose  or  two  of  the  trisnitrate  of  bismuth. 

9th.  I  have  never  known  depression  of  the  vital  powers,  or  more  than  tem- 
porary inconvenience,  to  follow  its  use  when  administered  in  the  mode  herein- 
after mentioned ;  although  I  can  readily  conceive  that  there  are  cases  in  which 
it  would  not  be  admissible.  In  the  selection  of  appropriate  cases,  and  discri- 
minating in  this  matter,  medical  men  must  have  recourse  to,  and  be  guided  by, 
their  experience  and  general  principles. 

10th.  Tartarized  antimony,  by  facilitating  and  shortening  the  process  of  par- 
turition, as  above  mentioned,  without  risk  to  the  uterine  apparatus  or  general 
system,  will,  we  may  confidently  expect,  by  conserving  the  vital  powers  and 
reducing  the  nervous  shock,  show,  on  more  extensive  trial,  favourable  statisti- 
cal results  in  the  mortality  attending  obstetric  practice. 

The  foregoing  observations  and  conclusions  have  not  been  arrived  at  hur- 
riedly, and  they  are  not  deductions  drawn  from  a  limited  number  of  cases,  or,  as 
you  are  aware,  from  a  limited  field  of  observation.  While  they  will  be  found 
correct  in  a  large  majority  of  cases,  I  am  free  to  admit  that  tartar  emetic  will 
not  in  all  cases  produce  the  same  results.  And,  indeed,  of  what  therapeutic 
agent  can  we  write  in  other  language  ?  Once  only  (six  or  seven  years  since)  I 
have  met  with  a  single  recorded  remark  that  would  lead  me  to  infer  that  the 
contractile  influence  to  which  I  have  referred  has  been  noticed  by  others.  I 
cannot  now  lay  my  hand  on  the  periodical  which  contains  it,  but  I  recollect  the 
writer  states  that,  after  injecting  two  grains  (I  think)  of  tartarized  antimony 
into  the  rectum  in  a  case  of  tedious  labour,  for  the  purpose  of  overcoming  mus- 
cular rigidity,  the  pains  very  shortly  became  stronger  and  more  effectual,  or 
ivords  to  that  effect. 

The  rationale  of  its  action  is  undoubtedly  to  be  referred  to  the  influence  tar- 
tarized antimony  exerts  on  the  sympathetic  system  of  nerves.  The  uterus,  like 
the  stomach  and  intestinal  canal,  is  composed  of  involuntary  or  unstriated  mus- 
cular fibre,  and  is,  like  the  other  abdominal  organs,  largely  dependent  for  ner- 
vous supply  on  the  sympathetic  system.  Now,  we  all  know  as  the  action  of 
antimony  on  these  hollow  abdominal  muscles  or  canals  :  that,  when  administered 
in  sufficient  quantity,  forcible  contractions  of  the  circular  and  longitudinal 
fibres  composing  them,  and  relaxation  of  the  sphincters,  take  place ;  just  what 
I  have  remarked  and  recorded  as  occurring  in  the  uterus.  Similarity  of  texture 
and  nervous  supply  would  then  analogically  point  to  that  which  experience  and 
observation  have  taught  me  is  in  reality  the  case  in  reference  to  the  action  of 
this  agent  in  the  uterus  in  the  act  of  parturition. 

Ergot  of  rye,  while  acting  primarily  and  with  more  energy  on  uterine  mus- 
cular fibre,  exerts  at  the  same  time  a  secondary  or  inferior  influence  on  the 
stomach,  often  producing,  as  I  have  before  remarked,  troublesome  vomiting. 

Now,  the  deduction  one  would  naturally  draw  from  the  above  observations  is, 
that  all,  or  most  of  what  are  termed  "  specific  emetics."  would,  through  the 
agency  of  the  sympathetic  system,  exert  their  contractile  influence  on  the 
uterus,  and  vice  versa,  as  just  illustrated  in  the  case  of  ergot — i.  e.,  therapeutic 
agents  which  cause  uterine  contractions  will  have  a  similar  action  on  the 
stomach  and  intestinal  canal.  I  have  not  administered  ipecacuanha  with  the 
same  object  in  view,  but  have  very  little  doubt  that  if  tried  it  will  be  found  to 
produce  like  results.  Its  taste  and  bulk  would,  however,  other  things  being 
equal,  give  a  preference  to  its  more  convenient  ally  tartar  emetic ;  while,  on 
the  other  hand,  its  depressing  effects  would  not  be  so  marked  in  cases  where  a 
continuance  of  the  medicine  should  be  considered  advisable.  In  this  connection 
I  may  remark  that  it  is  suggestive,  and  at  the  same  time  corroborative  of  the 
views  here  stated,  that  nausea  and  actual  vomiting,  occurring  naturally  during 
labour,  very  generally  advance,  and  often  materially  shorten  the  process,  by 
increasing  the  contractile  power  of  the  uterus.    I  administer  the  tartarized  an- 


1863.] 


Midwifery. 


515 


timony  as  follows  :  From  one  to  two  grains  are  dissolved  in  a  wineglassful  of 
water,  and  a  dessertspoonful  given  every  ten  or  fifteen  minutes  ad  nauseam ; 
and  if  the  pains  are  not  increased  sufficiently,  and  there  are  no  contra-indicating 
circumstances  present,  it  is  continued  beyond  this  point.  The  rectal  mode,  to 
which  reference  has  been  made,  has  its  advantages,  and,  at  the  same  time,  its 
inconveniences  ;  but  there  are  cases  in  which  it  should  have  the  preference. 

It  only  remains  for  me,  in  conclusion,  to  ask  the  members  of  this  Society  to 
give  the  subject  their  consideration,  to  note  at  the  time  the  results  attending 
its  administration,  and  not  to  report  their  conclusions  until  they  have  given  the 
matter  a  fair  and  somewhat  extended  trial. — Edinburgh  Med.  Journ.,  Jan.  1863. 

47.  Dropsy  of  the  Ovum. — Dr.  McClintock  read  before  the  Dublin  Obste- 
trical Society  (Dec.  13,  1862)  an  interesting  paper  on  this  affection,  illustrated 
by  a  number  of  cases. 

"It  must  be  confessed,"  he  remarks,  "we  know  very  little  of  the  pathology 
of  this  complaint,  or  of  the  special  conditions  which  give  rise  to  it.  In  very 
many  of  the  cases  which  have  fallen  under  my  observation  I  have  instituted 
careful  examinations  on  these  heads ;  yet,  in  but  few  examples  was  there  any 
notable  appearance  of  disease  of  the  amniotic  membrane.  In  these  exceptional 
cases  the  amnion  was  partially  opaque  and  thickened,  but  nothing  more.  That 
the  disease  does  not  depend  on  a  dropsical  diathesis  of  the  woman  herself  is 
shown  by  the  fact  that  these  women  are  often  free  from  dropsical  effusions  in 
any  other  part  of  the  system ;  and  also,  that  very  many  patients  are  affected 
with  general  dropsy  at  the  time  of  delivery,  in  whom,  nevertheless,  there  is  no 
marked  redundancy  of  the  amniotic  fluid."    *    *  * 

"A  dropsical  state  of  the  amnion  is  a  very  common  morbid  condition  of  abor- 
tive ova ;  and  I  cannot  help  thinking,  with  the  late  Professor  Andrew  Retzius, 
of  Christiania  (who  drew  my  attention  to  this  fact  when  looking  over  the 
Museum  of  the  Lying-in  Hospital),  that  it  is  a  very  frequent  cause  of  the  early 
death  and  expulsion  of  the  embryo. 

"  Of  thirty-three  cases  of  amniotic  dropsy  carefully  noted  by  me,  one  ended  in 
abortion  at  the  fifth  month,  and  one  at  the  sixth  month ;  ten  resulted  in  the 
decidedly  premature  expulsion  of  the  foetus ;  and  in  the  remainder  the  child 
seemed  to  have,  at  all  events,  reached  the  ninth  month,  though  in  some  of  them 
it  most  probably  had  not  completed  it. 

"  There  seems  good  reason  to  believe  that  some  of  the  cases  of  the  disease 
called  '  hydrometra,'  or  dropsy  of  the  womb,  were  of  the  kind  now  under  con- 
sideration— were,  strictly  speaking,  a  disease  of  the  ovum,  and  not  of  the  uterus ; 
just  as  the  so-called  hydatids  of  the  uterus  is,  in  truth,  a  disease  affecting  only 
the  involucra  of  the  embryo.  Many  of  the  recorded  cases  of  'hydrometra'  admit 
of  a  much  more  rational  explanation  of  their  history  and  phenomena,  and  one 
more  consistent  with  the  physiology  of  the  uterus,  on  this  supposition  than  on 
any  other  pathological  view. 

"This  morbid  excess  of  the  liquor  amnii,  or,  perhaps,  the  morbid  action  from 
which  it  results,  seems  to  be  very  unfavourable  to  the  well-being  of  the  foetus, 
as  nine  of  the  children  were  dead  born,  five  of  which  were  in  a  putrid  condition ; 
and  ten  of  the  live-born  children  died  within  a  few  hours  after  birth.  It  occurred 
more  frequently  with  female  than  with  male  children,  in  the  proportion  of  twenty- 
five  of  the  former  to  eight  of  the  latter.  The  great  difference  between  these 
numbers  is  very  remarkable,  and  would  almost  suggest  the  probability  of  there 
being  something  more  than  a  mere  accidental  association  of  this  disease  with 
children  of  the  female  sex. 

"The  presenting  part  of  the  child  was  noted  in  thirty-one  instances — and 
among  these  the  head  presented  on  twenty  occasions,  the  pelvic  extremity  nine 
times,  and  the  upper  extremity  once.  We  could  not,  from  these  numbers,  safely 
infer  that  a  redundancy  of  the  liquor  amnii  favoured  preternatural  presentation, 
because  there  is  another  circumstance  connected  with  these  cases  which  would 
go  far  to  account  for  it,  namely,  the  great  frequency  among  them  of  premature 
labour — of  the  thirty-three  cases  nearly  one-half  having  terminated  in  the  pre- 
mature expulsion  of  the  ovum. 

"In  the  acute  form  of  this  disease  it  would  perhaps  be  rather  difficult  to  trace 


516 


Progress  of  the  Medical  ScieiUces. 


[April 


the  symptoms  to  their  real  cause,  unless  the  dropsical  condition  of  the  amnion 
was  discoverable  by  physical  examination.  The  enlarged  uterus  may  be  con- 
founded with  plural  pregnancy,  or  with  ascites.  Where  there  is  much  distension 
of  the  uterus  a  feeling-  of  fluctuation  will  be  communicated,  with  great  distinct- 
ness, to  the  hand  on  percussing  the  abdomen,  so  that,  in  extreme  cases,  it  would 
be  impossible  to  arrive  at  a  positive  conclusion  by  thistnode  of  examination. 
Internal  examination  will  generally  supply  stronger  evidence.  The  expanded 
state  of  the  cervix,  the  extreme  tension  of  the  lower  segment  of  uterus  (or  of  the 
membranes,  if  the  os  be  open),  and  the  ease  with  which  the  child  can  be  dis- 
placed, are  all  corroborative  signs  of  the  ovum  being  unusually  distended  with 
fluid.  With  reference  to  the  last-mentioned  sign,  we  must  bear  in  mind  that  a 
dropsical  ovum  may  coexist  with  immobility  of  a  presenting  foetus. 

"Some  writers  have  stated  that  inaudibility  of  the  foetal  heart's  sounds,  and 
of  the  placental  murmur,  are  results  of  amniotic  dropsy.  But  this  observation 
can  only  be  received  in  a  very  qualified  manner.  No  doubt,  in  a  considerable 
proportion  of  these  cases  the  child  is  dead,  and  its  heart,  therefore,  inaudible ; 
in  many  of  them  the  patient  is  still  far  removed  from  the  end  of  pregnancy,  and 
this  in  itself  creates  a  difficulty  to  hearing  the  foetal  heart ;  but,  in  these  and 
the  remaining  cases,  we  may  generally  succeed  in  detecting  it,  as  I  myself  re- 
peatedly have  done,  by  persevering  and  diligent  exploration. 

"  In  a  few  instances  I  have  heard  the  placental  murmur  distinctly,  and  with 
all  the  characters  belonging  to  it.  In  these  cases  I  discovered  it  accidentally. 
Not  having  sought  for  it  in  any  of  the  cases,  I  cannot  say  whether  it  is  more  or 
less  easy  of  detection  than  under  ordinary  circumstances.  The  entire  superficies 
of  the  uterus  is  certainly  very  much  increased,  but  in  the  same  proportion  is  the 
placental  area  increased ;  and  I  have  little  doubt  it  is  the  interference  arising 
therefrom  to  the  placental  circulation  which  causes  so  many  of  these  foetuses  to 
be  born  in  a  dead  or  dying  state.  The  first  stage  of  labour  is  very  commonly 
protracted  in  these  cases  from  inertia,  caused  by  the  over-distension  of  the  ute- 
rine fibres.  Occasionally  the  cervix  is  completely  effaced,  and  the  mouth  of  the 
womb  in  a  somewhat  dilated  state  for  days ;  but  the  uterus  seems  incapable  of 
making  any  vigorous  effort  to  expel  its  contents,  or  to  rupture  the  membranes." 
■x-    *    *  '  f.  ; 

"A  question  of  deepest  interest  connected  with  this  disease  of  the  ovum  is  its 
influence  on  maternal  mortality.  Now,  of  the  33  cases  here  reported,  four  ended 
in  the  death  of  the  mother.  One  was  from  rupture  of  the  uterus  (the  child,  in 
this  instance,  was  hydrocephalic) ;  another  from  puerperal  fever,  at  the  time 
epidemic ;  and  the  other  two  deaths  were  from  debility  and  prostration.  Each 
of  these  latter  women  had  been  confined. of  twins,  and  were  in  a  broken-down 
state  of  health  at  the  time  of  delivery.  The  above  results  will  abundantly  justify 
the  observation,  that  a  comparatively  high  rate  of  mortality  may  be  expected 
amongst  patients  who  are  the  subjects  of  dropsy  of  the  ovum.  One  very  influ- 
ential reason  for  this  may  be  found  in  the  fact,  that  a  large  proportion  of  these 
women  are  in  a  more  or  less  cachectic  debilitated  condition  of  body;  in  fact  this 
state  may  be  regarded  as  a  strongly  predisposing  cause  of  the  disease.  Of  the 
women  who  recovered,  three  had  smart  attacks  of  uterine  inflammation  after 
delivery.  Altogether,  then,  it  is  plain  that  these  patients,  more  than  others, 
require  to  be  closely  watched  during  child-bed. 

"  I  know  of  no  treatment  capable  of  arresting  the  secretion  of  the  liquor  amnii, 
or  of  causing  its  absorption  where  already  secreted  to  an  excessive  amount.  I 
have  made  trial  of  mercury,  hydriodate  of  potash,  diuretics,  and  other  remedies, 
but  could  not  perceive  any  good  effect  from  their  employment.  Of  course',  when 
the  distension  of  the  uterus  becomes  enormous,  puncture  of  the  membranes  must 
be  performed,  even  though  labour  may  yet  seem  distant,  in  the  natural  course 
of  events.  The  patient  may  suffer  much  pain  and  discomfort,  apparently  con- 
nected with  the  disease  in  question :  but  where  as  yet  the  distension  of  the 
uterus  is  not  so  great  as  to  justify  a  measure  which  we  know  will  bring  on 
labour.  If  it  were  possible  to  draw  off  only  a  portion  of  the  fluid  contents  of 
the  amnion,  perhaps  labour  would  not  immediately  follow,  and  doubtless  great 
relief  would  accrue  to  the  patient,  who  could  thus  be  carried  forward  in  her 
pregnancy."    *    *  * 


1863.] 


Midwifery. 


517 


''The  effect  of  this  super-excess  of  liquor  amnii  upon  the  process  of  labour  is 
generally,  indeed  I  may  say  always,  to  retard  it.  The  pains  are  constant,  but 
not  severe — not  amounting  to  the  degree  of  a  regular  labour  pain ;  but  yet  they 
are  most  teazing  to  the  patient.  Very  many  hours,  or  even  days,  as  we  have 
seen,  may  be  consumed  in  this  way,  before  the  os  uteri  will  have  reached  the 
size  of  a  penny.  Under  circumstances  such  as  these,  and  where  the  accession 
of  labour  has  evidently  taken  place,  there  may  be  no  hesitation  about  letting  off 
the  water,  with  such  precautions  as  the  position  of  the  foetus  may  call  for."  *  * 

Dr.  McC.  thinks  that  the  facts  he  has  adduced  enlighten  on  the  following 
important  points : — 

"1.  Dropsy  of  the  ovum  certainly  does  not  depend  on  any  dropsical  diathesis 
of  the  patient  herself.    This  fact,  I  think,  is  clearly  established. 

"  2.  There  is  no  doubt,  also,  that  it  may  occur  quite  independently  of  any 
dropsical  condition  of  the  foetus,  such  a  concurrence  being  but  very  rarely  met 
with ;  and  hence  being,  we  may  presume,  purely  accidental. 

"3.  It  is  not  constantly  associated  with  any  appreciable  morbid  condition  of 
the  membranes  or  placenta ;  at  least  in  some  exceptional  cases  only  did  they 
present  any  deviation  from  their  ordinary  appearance. 

"4.  The  cause  of  the  dropsy  would  seem  to  be  a  purely  local  one.  This  is 
inferable  from  the  frequently  observed  fact  that  in  pleural  pregnancies,  where 
the  disease  was  present,  it  was  confined,  in  every  instance,  to  one  ovum  only. 

"  5.  My  experience  of  this  disease  does  not  lead  me  to  think  that  it  has  any 
connection  with  syphilis.  In  only  one  of  all  the  cases  on  which  these  observa- 
tions are  founded  was  there  any  just  ground  for  supposing  the  woman  to  be 
infected  with  syphilitic  poison.  In  this  exceptional  case,  father,  mother,  and 
child,  all  presented  unequivocal  venereal  symptoms. 

"With  regard  to  the  functions  of  the  amnion,  we  meet  with  three  classes  of 
facts  which  help  to  illustrate  them : — 

"1.  Oases  of  plural  births  occasionally  are  met  with  in  which  one  of  the 
foetuses  having  been  blighted,  the  fluid  contents  of  its  enveloping  amnion  have 
disappeared.    This  I  would  attribute  to  its  absorption  by  the  membrane  itself. 

"2.  Again,  we  meet  with  cases  in  which  the  liquor  amnii  presents  a  very 
altered  appearance — all  its  sensible  characters  being  changed,  and,  instead  of 
being  transparent,  thin,  and  inodorous,  it  is  thick,  turbid,  and  fetid.  This  is  an 
instance  of  morbid  or  perverted  secretion. 

"3.  Lastly,  we  have  seen  that  the  quantity  of  the  secretion  maybe  enormously 
increased. 

"These  facts  all  concur  in  strengthening  the  analogy  between  the  amnion  and 
serous  membranes,  by  showing  that  it  can,  under  certain  circumstances,  increase, 
absorb,  or  alter  its  proper  secretion. 

"All  this  does  not  carry  us  far,  however,  towards  explaining  how  the  disease 
in  question  is  produced.  But  I  believe  we  must  rest  content  with  this  limited 
amount  of  knowledge  till  physiologists  make  us  better  acquainted  with  the  vital 
constitution  of  the  amnion  and  other  temporary  organs  concerned  in  the  nutri- 
tion and  development  of  the  foetus." 

48.  Unusual  Density  of  the  Amnion. — Dr.  Sawyer  read  before  the  Obstetri- 
cal Society  of  Dublin  (Jan.  10,  1863)  a  paper  on  this  subject. 

On  the  8th  of  June,  1861,  he  was  hurriedly  sent  for  to  see  a  woman  at  the 
hospital  whose  "  womb  was  turned  inside  out."  On  going  to  the  labour-couch 
he  found  a  nurse  of  considerable  experience  in  a  state  of  trepidation,  pressing  a 
napkin  against  the  vulva.  On  examination  he  found  a  dark  mass,  about  the  size 
and  shape  of  a  small  melon,  protruding.  On  pressing  the  tumour  the  fluctuation 
relieved  his  mind.  He  found  the  womb  of  the  usual  size,  and  the  amnion  unusu- 
ally dense  and  opaque,  the  rent  through  which  the  child  passed  being  unusually 
small.    In  the  next  case  he  had  had  forty-eight  hours'  suspension  of  labour  from 

density  of  the  amnion.    The  Registrar  requested  him  to  visit  Mary  M  ,  and 

stated  that  as  all  pain  had  ceased  for  the  two  last  days,  he  had  the  forceps  with 
him,  a  number  of  pupils  being  on  the  look-out  for  an  operation.  On  reaching 
the  house  he  (Dr.  Sawyer)  found  the  place  crowded  with  people,  one  of  whom, 
recognizing  him,  cried  out,  "  Oh,  here 's  th'  ould  docther ;  run  for  the  priest, 


518 


Progress  of  the  Medical  Sciences. 


[April 


Biddy/'  an  expression  of  her  confidence  which  he  duly  appreciated  (laughter). 
The  woman's  health  had  been  good.  It  was  her  fourth  child.  Labour  pains  set 
in  on  Thursday  night,  and  continued  until  the  following  Friday  evening,  when 
they  gradually  ceased.  The  midwife  thought  the  waters  had  broken,  but  as  the 
woman  had  incontinence  of  urine  for  some  weeks,  she  could  not  be  certain.  The 
great  size  of  the  uterus  convinced  him  that  the  membranes  were  whole.  He  found 
the  os  greatly  dilated,  and  concluded  that  the  delay  was  caused  by  over-secretion 
and  the  unusual  density  of  the  membranes.  He  gave  her  half  a  drachm  of  ergot 
in  a  tumbler  of  punch,  and  in  ten  minutes  the  bag  became  prominent,  but  he 
could  not  rupture  it.  either  with  his  finger  or  tooth-pick,  and  was  obliged  to 
resort  to  the  bistoury,  when  the  waters  rushed  out,  and  labour  was  complete. 
His  third  case  was  one  that  occurred  early  in  December.  In  the  first  confine- 
ment of  the  patient  he  had  had  the  privilege  of  Dr.  Churchill's  assistance;  and 
in  her  second  confinement,  in  which  there  was  a  remarkable  case  of  secondary 
hemorrhage,  he  had  the  advantage  of  Dr.  Kidd's  assistance.  When  called  in  on 
the  last  occasion,  the  second  stage  was  completed.  Having  in  her  first  confine- 
ment experienced  considerable  difficulty  in  suppressing  hemorrhage,  he  took 
more  than  usual  care.  He  put  on  the  binder,  and  placed  a  dry  napkin  over  the 
vulva.  He  then  left  the  room  for  fifteen  minutes,  and  on  returning,  the  nurse 
showed  him  the  napkin  quite  dry.  Struck,  however,  with  the  pallid  hue  of  the 
patient,  he  took  off  the  binder  and  passed  his  hand  up  the  vagina,  when  he  found 
a  soft  tumour  protruding  through  the  partially  closed  cervix.  While  making 
the  examination,  there  was  a  most  alarming  rush  of  blood,  followed  by  contrac- 
tion of  all  portions  of  the  uterus,  compelling  him  to  extract  the  uterus. — Dublin 
Med.  Press,  Jan.  21,  1863. 

49.  Dislocation  of  the  Ensiform  Cartilage  during  Pregnancy. — Dr.  Robert 
Sim  relates  [Edinburgh  Medical  Journal,  February,  1863),  the  following  unique 
case  of  this  accident : — 

"  The  lady  in  whose  case  the  eversion  took  place  is  rather  under  middle 
height,  of  a  symmetrical  form,  and  in  the  prime  of  life. 

"  About  the  end  of  the  sixth  month  of  her  recent  pregnancy,  which  was  her 
fifth,  she  began  to  complain  of  great  pain  in  the  right  side ;  but,  as  Dr.  Mackay 
observes,  it  would  be  difficult  to  ascribe  this  pain  to  the  eversion  of  the  ensiform 
cartilage.  There  was  pain  at  the  place  where  it  was  turned  over,  but  there 
was  also  great  pain  lower  down,  in  the  right  hypochondriac  region,  the  cause  of 
which  I  must  leave  to  you  to  explain,  as  I  know  of  no  satisfactory  reason  given 
for  the  existence  of  these  very  violent  pains,  sometimes  so  distressing,  during 
the  last  months  of  pregnancy. 

"The  patient  was  delivered  of  twins  in  the  month  of  October  last,  and  my 
attention  was  drawn  by  her  to  a  '  lump'  under  the  right  mamma,  a  few  days 
after  the  confinement.  I  must  tell  you  that  this  lady  lives  in  constant  dread  of 
cancer  of  the  breast,  and  that,  when  she  drew  my  attention  to  the  swelling,  she 
evidently  supposed  it  to  be  a  scirrhous  tumour.  For  two  or  three  days  I  was 
afraid  that  her  fears  were  too  justly  entertained;  but,  after  observing  the 
tumour  for  a  few  days  longer,  I  was  gratified  to  find  that  it  was  gradually  dimi- 
nishing in  its  circumference,  and  that  the  hard  central  part  was  also  changing 
its  form  and  position.  In  short,  I  soon  discovered  that  the  hard  central  part  of 
the  swelling,  which  remained  after  the  disappearance  ol  the  surrounding  tume- 
faction, was  simply  the  ensiform  cartilage,  which  had  been  gradually  everted, 
pressed  upwards,  and  turned  over  to  the  right  side  by  the  encroachment  of  the 
gravid  uterus.  On  the  uterine  pressure  being  removed,  the  cartilage  gradually 
rose  from  its  abnormal  position.  At  first  I  could  hardly  insert  my  forefinger 
between  it  and  the  cartilages  of  the  ribs  on  which  it  lay.  After  some  time  it 
was  at  right  angles  to  the  sternum,  and  thenceforth  its  progress  to  its  own  place 
was  more  rapid.  At  the  end  of  the  sixth  week  from  parturition,  the  cartilage 
had  resumed  its  proper  position. 

"There  was  nothing  unusual  in  the  labour.  Its  duration  was  only  about 
three  hours.  The  presentations  were — first  feet,  next  head.  The  liquor  amnii 
was  not  unusually  abundant,  nor  was  there  anything  remarkable  about  the  size 


1863.] 


Midwifery. 


519 


of  the  placentae.  The  twins,  together,  weighed  twelve  and  a  half  pounds  avoir- 
dupois.   The  former  births  were  all  single. 

"  The  length  of  the  sternum  is  seven  inches,  that  of  the  ensiform  cartilage 
rather  more  than  two.  The  distance  from  the  sternum  to  the  pubis  I  have  not 
ascertained,  nor  other  abdominal  measurements." 

50.  Pessary  retained  Thirteen  Years. — Dr.  Kidd  exhibited  to  the  Obstetrical 
Society  of  Dublin  (Jan.  10,  1863)  a  pessary  which  he  had  removed  from  the 
vagina  of  a  woman  on  the  previous  day.  She  stated  that  he  had  himself  intro- 
duced it  for  her  thirteen  years  previously,  and  that  she  allowed  it  to  remain 
with  the  greatest  comfort  to  herself  until  within  the  last  fortnight,  when  she 
began  to  experience  a  pain  in  the  back,  while  some  discharge  took  place  from 
the  vagina.  The  string  had  broken  soon  after  it  was  put  in,  so  that  she  was  not 
able  to  remove  it.  The  pessary  was  composition — a  mass  of  tow  covered  over 
with  India-rubber.  He  effected  its  removal  by  introducing  one  of  the  blades  of 
Dr.  Churchill's  forceps,  which  he  got  above  the  mass,  extracting  it  with  the 
greatest  difficulty.  In  another  case  he  removed  a  pessary  after  a  year,  and  on 
that  occasion  he  had  recourse  to  both  blades  of  Dr.  Churchill's  forceps.  The 
pessary  was  coated  over  with  an  immense  mass  of  calcareous  matter. — Dublin 
Med.  Press,  Jan.  21,  1863. 

51.  Suprapelvic  Hematocele. — In  the  accounts  given  of  this  affection,  the 
blood  is  generally  described  as  being  contained  in  the  peritoneal  cul-de-sac 
behind  the  uterus,  and  as  forming  a  tumour  capable  of  being  felt  through  the 
rectum  and  vagina,  and  sometimes  by  pressure  in  the  hypogastric  region.  Some 
cases,  however,  which  have  come  under  M.  Gosselin's  observation,  have  led  him 
to  the  conclusion  that  the  effusion  from  the  ovary  may  (from  some  as  yet  un- 
known cause)  be  arrested  above  the  pelvis,  and  form  a  tumour  capable  of  being 
detected  by  palpation  in  the  hypogastric  region  alone,  and  not  by  the  vagina 
or  rectum.  One  patient  under  his  care  presented  on  two  separate  occasions, 
after  symptoms  resembling  those  of  peritonitis,  a  tumour  of  the  size  of  a  fist  in 
the  left  side  of  the  abdomen ;  it  disappeared  readily  each  time,  without  any  dis- 
charge of  pus  by  the  alvine  excretion,  by  the  urine,  or  by  the  vagina.  M.  Gos- 
selin  proposes  to  term  this  variety  "  suprapelvic  hematocele." — British  Med. 
Journal,  June  7,  1863,  from-  Gaz.  des  Hopitaux,  19  Avril,  1862. 

52.  Placentae  of  Triplets. — Dr.  Grtmsdale  showed  a  specimen  of  placentae  of 
triplets  to  the  Liverpool  Medical  Institution  (December  11, 1862).  All  the  three 
children  are  now  alive.  Two  of  them  measured  each  eighteen  inches  in  length, 
and  the  other  seventeen ;  they  were  strong  children.  The  placentae  were  by  no 
means  small ;  two  of  them  were  connected  together,  the  third  was  quite  sepa- 
rate.— British  Medical  Journal,  January  10,  1863. 

53.  Induration  of  the  Sterno-Gleido-Mastoid  Muscle  in  New-Born  Infants. — 
Dr.  Melchiori,  calls  attention  to  occasional  occurrence  in  new-born  infants  of 
an  induration  of  the  sterno-cleido-mastoid  muscle;  an  affection  not  hitherto 
described,  we  believe,  by  any  writer. 

Some  time  after  birth,  an  infant  is  occasionally  observed  to  move  its  neck  with 
difficulty  and  to  suffer  more  or  less  pain  from  such  movement.  On  examination, 
there  will  be  found  in  the  substance  of  one  of  the  sterno-mastoid,  a  hard  fusiform 
tumour  of  sometimes  notable  size.  In  all  the  cases  observed  by  Dr.  M.,  the 
tumour  disappeared  by  resolution  and  the  muscle  recovered  its  functions.  The 
disease  at  the  onset  appearing  inflammatory,  emollients  are  indicated,  afterwards 
the  treatment  is  expectant.  Dr.  M.  cannot  ascribe  the  affection  to  any  well 
determined  cause ;  but  he  thinks  that  it  may  be  attributed  to  the  compression  of 
the  muscle,  and  to  the  rupture  of  some  of  its  fibres  during  delivery. 

Dr.  Dolbeau  has  recently  observed  a  case  of  this  at  the  H6pital  St.  Louis,  in 
a  new-born  infant.  The  tumour  was  of  the  size  of  a  large  almond,  and  was 
seated  in  the  right  sterno-mastoid  muscle — there  was  no  discolorization  of  the 
skin. — Gazette  Hebdomadaire  de  M6d.  et  de  Chirurg.,  19  Sept.  1862,  and 
Annali  Omoclei. 


520  Progress  of  the  Medical  Sciences.  [April 


MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 

54.  Dialysis  as  applied  to  the  Detection  of  Poisons  in  Medico-legal  Cases. — 
Mr.  E.  R.  Harvey,  Lecturer  on  Physical  Chemistry  at  St.  George's  Hospital, 
relates  (Lancet,  Jan.  3,  1863)  a  number  of  experiments  made  by  him  in  the 
laboratory  of  the  St.  George's  Hospital,  with  a  view  of  determining  the  value  of 
dialysis  as  a  method  of  separating  poisons  from  organic  mixtures.  From  these  ex- 
periments, he  states,  it  appears  that  metallic  poisons  are  detected  far  more  rapidly 
by  dialysis  than  are  organic  substances ;  that  the  presence  of  colloidal  matter 
does  hinder,  to  some  extent,  the  separation  even  of  the  inorganic  crystalloids ; 
and  that  if  colloidal  matter  be  placed  on  a  dialyser,  a  small  quantity  of  it  will 
be  found,  in  twenty-four  hours,  in  the  diffusate.  Thus,  although  dialysis  may 
in  some  medico-legal  cases  be  of  assistance  to  the  chemist,  it  would  be  dangerous 
to  regard  it  as  a  substitute  for  the  old  and  approved  methods  of  analysis  when 
poison  is  suspected. 

55.  Poisoning  of  a  Child  by  a,  large  Dose  of  Morphia. — Mr.  L.  Winter- 
botham  records  (Lancet,  Jan.  3,  1863)  a  case  in  which  a  child  two  years  and 
three  months  old,  swallowed  a  solution  of  a  grain  of  acetate  of  morphia  in  an 
ounce  of  oxymel  of  squills.  It  remained  undisturbed  in  the  system  for  two 
hours  and  a  half.  At  the  end  of  this  period  free  vomiting  was  induced  by  an 
emetic  of  sulphate  of  zinc,  and  under  the  use  of  the  ordinary  remedies  recovery 
took  place. 

56.  Poisoning  by  Morphia — Caffeine  as  an  Antidote. — Dr.  Anstie  records 
(Med.  Times  and  Gaz.,  Feb.  7,  1863)  a  case  of  poisoning  by  three  grains  of 
morphia  given  inadvertently  as  an  injection.  Caffeine  was  given  with  temporary 
benefit,  but  the  patient  died  16|  hours  after  the  administration  of  the  enema. 

This  case,  Dr.  A.  says,  signally  refutes  the  notion  which  unaccountably  pre- 
vails that  opiates  do  not  act  so  powerfully  when  given  by  the  rectum  as  by  the 
mouth. 

Dr.  A.  views  favourably  the  plan  of  treating  such  cases  by  caffeine  as  recom- 
mended by  Dr.  Campbell,  of  Augusta,  Ga.,  and  successfully  employed  by  him  in 
one  case  (see  this  Journal  for  July,  1860,  p.  282),  though  it  failed  in  another 
(see  this  Journal  for  Oct.  1860,  p.  570). 

"The  teaching,"  he  says,  "of  all  the  experiments  which  have  been  made  with 
caffeine  is,  that  this  substance  has  a  very  powerful  stimulating  influence  upon 
the  heart,  as,  indeed,  we  might  expect  beforehand,  from  familiar  acquaintance 
with  the  effects  of  its  diluted  form — coffee  and  tea.  The  action  of  the  heart 
being  once  roused,  the  languid  circulation  of  the  brain  is  quickened,  and  the 
patient  is  restored  to  a  certain  degree  of  consciousness,  perhaps  sufficient 
to  enable  him  to  take  part  in  the  measures  adopted  for  his  recovery.  For 
these  reasons,  it  appears  to  me  that  caffeine  is  an  appropriate  physiological 
antidote  to  opium — far  more  so,  at  any  rate,  than  belladonna,  towards  which 
attention  seems  to  have  been  attracted  solely  on  account  of  the  apparent  oppo- 
sition between  its  effects  and  those  of  opium  on  the  pupil,  which  appears  to  me 
an  insufficient  basis  for  the  hypothesis  that  the  two  agents  are  mutually  antago- 
nistic in  their  effects  on  the  nervous  system  generally.    *    *  * 

"  It  must  be  remembered  that  opium  kills,  by  causing  a  cessation  of  the 
respiratory  movements.  One  of  the  best  means  to  meet  this  danger  is,  doubt- 
less, the  employment  of  artificial  respiration;  but  a  far  better  way  of  preventing 
its  occurrence  at  all  is  to  keep  the  brain,  and,  consequently,  the  intelligence  and 
consciousness,  in  a  state  of  activity.  If  once  a  patient,  suffering  from  opium 
poisoning,  becomes  thoroughly  unconscious,  he  becomes  unable  to  make  those 
voluntary  efforts  at  respiration  which  are  far  more  likely  to  prevent  its  cessation 
than  artificial  processes  are  to  restore  it  when  once  it  has  ceased. 

"  Now,  there  can  be  little  doubt  that  caffeine  quickens  the  circulation  gen- 
erally ;  and  there  are  some  special  reasons  for  thinking  that  it  especially  exerts 


1863.] 


Medical  Jurisprudence  and  Toxicology. 


521 


an  influence  upon  the  circulation  of  the  brain ;  it  would,  therefore,  be  well 
adapted  to  this  particular  purpose." 

57.  Poisoning  ivith  Belladonna  successfully  treated  with  Opium. —  [This 
is  the  heading  to  the  following  case  recorded  in  the  Dublin  Quarterly  Journal 
of  Medical  Science,  February,  1863.  "We  extract  it,  though  we  must  say  that 
we  do  not  attach  much  value  to  it  as  adding  anything  to  the  facts  already  re- 
corded showing  the  antagonistical  action  of  belladonna  and  opium.  The  case 
is  too  imperfectly  detailed  ;  there  is  not  sufficient  evidence  that  the  child  took  a 
decidedly  poisonous  dose  of  the  belladonna,  and  further  the  amount  of  opium 
which  sufficed  to  arrest  the  symptoms  was  so  small  that  we  cannot  but  suspect 
the  patient  might  have  got  well  without  the  administration  of  the  antidote.] 

"  John  Mulligan,  aged  two  years  and  two  months,  was  admitted  into  the  Meath 
Hospital,  under  the  care  of  Surgeon  Macnamara,  on  the  31st  day  of  ,  October, 
1862,  labouring  under  the  effects  of  poisoning  by  belladonna. 

"  History.— His  mother  stated  that  she  lives  at  Rose  Hall,  Templeogue, 
County  Dublin,  and  that,  about  half-past  nine  o'clock  this  morning,  the  child  got 
into  an  empty  room  in  which  there  was  a  small  pot  containing  extract  of  bella- 
donna, of  which  the  child  must  have  taken  some,  for  she  found  his  face  and 
clothes  smeared  over  with  it.  Some  time  after  she  saw  the  child  fall,  and  then 
remarked  that  he  had  a  wild  look  about  the  eyes,  upon  which  she  brought  him 
into  hospital  at  half-past  three  o'clock  P.  M. 

"  Symptoms. — On  examination  I  found  the  pulse  strong,  the  pupils  greatly 
dilated,  he  picked  and  pulled  at  his  clothes,  and  was  delirious.  The  mother 
having  brought  the  pot  which  was  found  with  the  child,  the  contents  were  at 
once  recognized  to  be  extract  of  belladonna. 

"  Treatment. — On  the  patient  being  put  to  bed  I  gave  an  emetic  consisting 
of  sulph.  of  zinc.  gr.  x,  and  pulv.  ipec.  gr.  vi,  which  had  the  desired  effect ;  the 
matter  vomited  had  no  trace  of  belladonna.  Surgeon  Macnamara  having  been 
sent  for,  ordered  an  enema  of  castor  oil  and  turpentine  to  be  given,  which  came 
away  without  any  signs  of  belladonna  being  present  in  it.  A  short  time  after, 
five  drops  of  tincture  of  opium  were  given ;  after  one  hour  three  drops,  and 
every  hour  after  two  drops,  until  the  patient  fell  asleep,  which  was  at  a  quarter 
before  one  o'clock  A.  M.,  up  to  which  time  there  was  no  apparent  contraction 
of  the  pupils.  He  slept  quietly  until  ten  minutes  before  two  o'clock,  when  he 
started  up  and  began  crying.  I  then  remarked,  for  the  first  time,  that  the  pupils 
had  contracted  a  little ;  he  fell  asleep  again  in  about  five  minutes,  and  slept 
quietly  until  half-past  six  o'clock  A.  M.,  when  all  the  delirium  had  passed  away, 
and  the  pupils  were  a  little  more  contracted.  He  has  been  running  about  the 
ward  all  day. 

"  Result. — November  1st,  at  12  o'clock,  Surgeon  Macnamara  ordered  two 
drops  of  the  tincture  of  opium  to  be  given,  and  he  has  been  going  on  remark- 
ably well  ever  since ;  six  o'clock  P.  M.,  going  on  well,  contraction  of  the  pupils 
apparent;  ten  o'clock  P.M.,  sleeping  soundly. 

"  November  2d,  three  o'clock  A.  M.,  slept  soundly  all  night,  the  pupils  still  a 
little  dilated.    Ten  o'clock  A.  M..,  the  patient  has  left  the  hospital  cured." 

58.  Rupture  of  the  Heart  attributed  to  direct  Violence. — Dr.  Dickinson  ex- 
hibited to  the  Pathological  Society  of  London  (Jan.  6, 1863)  a  specimen  of  this. 
The  subject  from  whom  it  was  obtained  was  a  child  5  years  of  age,  who  was 
knocked  down  and  run  over  by  a  cart.  When  brought  to  the  Hospital  she  was 
quite  dead.  There  was  no  mark  of  injury  upon  any  part  of  the  body.  At  the 
post-mortem  the  pericardium  was  found  to  be  full  of  blood,  which  had  issued 
from  a  transverse  rent  across  the  apex  of  the  heart,  which  cut  off  all  but  a  sort 
of  fringe  on  the  anterior  aspect.  Both  ventricles  were  laid  op'en.  The  muscular 
substance  was  torn  to  a  greater  extent  than  the  pericardium.  The  spine  and 
ribs  were  unbroken,  and  there  was  no  injury  to  any  other  organ.  It  was  obvious 
that  the  injury  to  the  heart  had  been  occasioned  by  the  accident.  A  sudden 
spasmodic  action,  from  terror  or  exertion,  even  if  sufficient  to  rupture  the  per- 
fectly healthy  heart  of  a  child,  which  is  highly  improbable,  could  scarcely  be 
supposed  to  tear  both  ventricles  in  exactly  adjoining  situations.  Moreover, 


522 


Progress  op  the  Medical  Sciences. 


[April 


when  the  heart  is  ruptured  spontaneously  it  is  almost  always  found  that  the  rent 
is  considerably  higher  up  the  wall  of  the  ventricle  than  in  the  present  case.  Dr. 
Dickinson  concluded  that  the  cart  had  passed  over  the  back  of  the  child,  and 
compressed,  without  breaking,  the  yielding  structures  of  the  thorax,  so  as  to 
squeeze  off  the  apex  of  the  heart  by  means  of  some  prominent  bone,  probably 
a  rib.  It  must  be  noted  that  the  rupture  commenced  on  the  posterior  aspect 
of  the  heart. 

A  case  was  then  related  of  a  patient,  thirty-five  years  of  age,  whose  leg  had 
been  crushed  by  a  gate  falling  on  it.  The  leg  was  amputated ;  the  man  died 
suddenly  some  days  afterwards.  The  right  ventricle  was  found  to  be  ruptured, 
probably,  in  this  case,  from  mental  emotion. 

Mr.  Hutchinson  mentioned  a  similar  case.  In  it  a  child  was  knocked  down 
in  the  street,  and  died  on  its  way  to  the  London  Hospital.  There  was  no  mark 
of  bruise  on  the  chest  nor  any  fracture  of  rib,  but  the  heart  was  found  ruptured  ; 
the  right  lung  near  its  root  was  also  torn.  The  evidence  was  conflicting  as  to 
whether  or  not  the  wheel  had  passed  over  the  child,  but  in  all  probability  it  had 
done  so.  The  elasticity  of  the  walls  of  the  chest  in  children  might  account  for 
the  non-occurrence  of  fracture  of  ribs,  and  the  fact  that  death  took  place  from 
sudden  and  complete  arrest  of  the  heart's  action,  for  the  entire  absence  of 
bruising  or  ecchymosis. 

Dr.  Brinton  said  that  rupture  of  the  heart  would  follow  the  most  severe  acci- 
dents, for  instance,  a  blow  on  the  head.  He  could  scarcely  accept  Dr.  Dickin- 
son's theory  of  the  cause  of  rupture  in  his  specimen. 

Dr.  C.  J.  B.  Williams  alluded  to  great  contraction  of  the  walls  of  the  ventricle 
in  the  specimen  exhibited. 

Dr.  Leared  related  a  case  in  which  a  man  died  suddenly  after  the  fall  of  part 
of  a  wall  on  him.  The  pericardium  was  full  of  blood,  and  there  was  a  jagged 
rupture  of  the  ventricle. 

Mr.  Spencer  Wells  related  a  case  in  which  a  sailor,  having  been  struck  on 
the  chest  by  an  officer,  walked  away  and  died  shortly  afterwards,  whilst  vomit- 
ing. There  was  a  small  aneurism  of  the  aorta,  which  had  been  ruptured.  Tire 
question  raised  on  the  trial  was,  whether  death  was  due  to  the  blow  or  not  ? — 
Med.  Times  and  Gaz.,  Jan.  3,  1863. 


MISCELLANEOUS. 

59.  State  of  Epidemic  Disease  in  Great  Britain  in  1861-'62. — Dr.  J.  N. 
Radcltffe  read  a  detailed  report  on  this  subject  before  the  Epidemiological 
Society  *(Dec.  1,  1862). 

The  report  referred  to  the  twelve  months  ending  September  30,  1862.  The 
following  is  a  recapitulation  of  some  of  the  principal  facts  recorded  :  The  health 
status  of  the  English  population,  as  estimated  from  the  unusually  low  rate  of 
mortality  throughout  the  year,  was  generally  good,  notwithstanding  dearness  of 
provisions  and  an  excessive  amount  of  pauperism.  The  health  status  of  the 
Scottish  population  was  markedly  below  the  average,  as  shown  by  the  large 
amount  of  sickness  prevalent  in  the  last  quarter  of  1861,  and  the  high  rate  of 
mortality  since  the  commencement  of  1862.  The  average  death-rate  of  Scot- 
land, it  is  well  to  remark,  is  below  that  of  England.  Thus,  during  the  six  years 
1855-60,  the  annual  proportion  of  deaths  in  England  was  219  per  10,000  popu- 
lation :  during  the  same  period  in  Scotland  the  proportion  was  208.  The  high 
range  of  temperature  in  the  winter  months,  and  low  range  during  the  summer, 
in  England,  exercised  a  favourable  influence  over  the  health,  notwithstanding 
much  wet  and  variability  of  weather.  In  Scotland  similar  conditions  of  tempe- 
rature and  weather  existed,  but  to  an  exaggerated  extent ;  and  the  great  changes 
which  were  experienced,  and  especially  the  undue  humidity  of  the  atmosphere, 
were  apparently  the  fostering  causes  of  the  influenza  and  throat  affections, 
which  appear  to  have  been  more  common  there  than  in  England.   The  epidemic 


1863.] 


Miscellaneous. 


523 


diseases  most  prevalent  in  England  were  continued  fever,  scarlatina,  measles, 
diphtheria,  whooping-cough,  and  smallpox.  In  Scotland  the  same  diseases, 
with  the  exception  of  smallpox ;  also,  and  more  particularly,  sore-throat,  often 
assuming  a  diphtheritic  character,  and  accompanied  by  diphtheria,  played  the 
chief  part  in  the  epidemiology  of  the  twelve  months.  In  both  parts  of  the  kingdom 
continued  fever  prevailed  most  commonly  in  the  autumn  quarter  of  1861 ;  and  in 
England  the  affection  would  appear  to  have  been  more  general  in  the  northern 
than  in  the  southern  portion  of  the  kingdom.  In  both  countries  scarlatina  was 
widely  prevalent  in  the  northern  districts  in  the  last  quarter  of  1861 ;  but  the 
disease  became  more  active  in  the  southern  district  in  the  third  quarter  of  1862. 
Measles  prevailed  extensively,  and  in  some  instances  very  fatally,  in  the  winter 
quarter  in  England.  In  Scotland  the  disease  appears  to  have  been  most  preva- 
lent in  the  spring  and  summer  quarters.  Diphtheria  was,  in  England,  princi- 
pally fatal  in  the  autumn  quarter,  but  the  disease  prevailed,  more  or  less,  in 
every  registration  district  during  the  year.  In  Scotland,  the  disease,  together 
with  sore-throat,  appears  to  have  been  epidemic  throughout  the  year.  Whoop- 
ing-cough was  widely  prevalent  in  England  during  the  winter  quarter ;  in  Scot- 
land, during  the  winter  and  spring  quarters.  Influenza  was  epidemic  in  Scot- 
land in  the  autumn  and  winter  quarters.  Finally,  smallpox  broke  out  in  many 
districts  of  England,  but  more  particularly  in  the  eastern,  southwestern,  and 
northern  counties,  and  in  Yorkshire.  In  no  instance  did  an  outbreak  of  any  of 
the  different  diseases  referred  to  as  occurring  in  England  assume  what  may  be 
termed  "general  proportions."  The  outbreaks  were  essentially  local ;  but  the 
dispersion  of  the  various  maladies,  or  of  their  centres  of  manifestation,  over  the 
kingdom — the  cropping  out  of  exaggeration  of  these  diseases  in  different  locali- 
ties, and  the  effects  they  apparently  exercised  upon  the  sickness  and  mortality 
of  certain  districts,  without  heightening  the  death-rate  of  the  whole  kingdom — 
present  a  study  of  great  interest.  From  this  study  it  is  reasonable  to  conclude 
that,  in  dealing  with  these  local  outbreaks  of  epidemic  disease  in  ordinary 
periods,  the  best  chance  is  afforded  of  warding  off  the  widespread  and  more 
deadly  outbreaks  of  extraordinary  periods.  The  detailed  mortuary  returns  for 
Scotland  extend,  as  yet,  only  to  the  year  1857 ;  but  the  returns  for  England  are 
brought  down  to  1860.  From  the  latter,  then,  may  be  obtained  information  as 
to  the  status  of  the  several  epidemic  diseases  most  prevalent  in  the  twelve 
months  discussed,  immediately  prior  to  that  period.  Since  1857  the  mortality 
from  continued  fever  has  slowly  declined ;  in  that  year  the  deaths  from  this 
cause  amounted  to  19,016 ;  in  1860  they  were  13,012.  In  1855  the  mortality 
from  scarlatina  was  17,314;  in  1856  and  1857,  the  number  of  deaths  from  this 
disease  fell  considerably,  the  mortality  in  the  latter  year  being  12,646.  The 
year  following  the  mortality  increased  enormously,  becoming  well  nigh  doubled, 
the  number  of  deaths  from  the  malady  being  23,711.  In  1859  the  number  fell 
to  19,310  ;  and  in  1860  it  became  as  low  as  9305.  Prior  to  1855  deaths  from 
scarlatina,  cynanche  maligna,  and  diphtheria,  were  not  separated  in  the  Eegis- 
trar-Greneral's  report.  Whether  the  detailed  reports  of  the  Eegistrar-General 
will  show  an  increase  of  the  mortality  in  the  whole  of  England  from  scarlatina, 
during  1861  and  1862,  as  great  as  occurred  in  London,  cannot  be  predicted.  It 
is  certain,  however,  that  the  activity  of  scarlet  fever  was  great  in  several  parts 
of  the  kingdom.  The  deaths  from  cynanche  maligna  in  1855  amounted  to  199; 
in  1858,  to  1770;  in  1860,  the  mortality  from  the  disease  had  decreased  to  376. 
The  mortality  from  measles  was  largely  augmented  in  1858,  and  there  was  a 
steady  increase  in  the  number  of  deaths  from  the  disease  in  the  two  subsequent 
years.  The  deaths  registered  from  diphtheria  in  1855  numbered  186  ;  in  1859, 
9587 ;  in  1860,  the  mortality  from  this  disease  had  decreased  to  5212.  The  mor- 
tality from  whooping-cough,  in  1860,  was  the  lowest  since  1852 ;  and  the  mor- 
tality from  smallpox  had  declined  from  6460  in  1858,  to  2749  in  1860.  The 
reduced  rate  of  mortality  throughout  England  which  occurred  in  1860,  was 
chiefly  due,  Dr.  Farr  states,  to  the  decline  of  the  number  of  deaths  from  scarla- 
tina, diphtheria,  and  diarrhoea.  A  decrease  also  in  the  mortality  from  smallpox, 
erysipelas,  and  cholera  contributed  to  the  favourable  results.  The  most  note- 
worthy fact  in  the  epidemiology  of  the  metropolis  during  the  twelve  months 
was  the  remarkable  outbreak  of  typhus.    In  1858,  1859,  and  1860,  typhus  had 


524 


Progress  of  the  Medical  Sciences. 


[April 


become  so  rare  a  disease  in  London,  that  the  question  of  converting  the  Fever 
Hospital  to  other  uses  was  seriously  entertained.  In  1861  typhus  again  became 
epidemic  ;  and  since  January,  1862,  the  number  of  admissions  to  the  Fever  Hos- 
pital for  typhus  has  exceeded  that  at  any  period  of  the  history  of  the  Hospital. 
Dr.  Murchison  attributes  this  epidemic  to  the  artificial  scarcity  produced  by  the 
system  of  strikes,  which  had  for  some  time  previously  disorganized  the  labour 
market,  and  the  condensation  of  population  caused  by  the  arrival  of  labourers 
in  the  metropolis  from  the  country  in  search  of  work.1  The  mortality  from  con- 
tinued fever  in  London,  doubtless  owing  to  the  outbreaks  of  typhus,  was  in 
excess  of  that  of  any  like  period  since  1848.  Indeed,  the  total  mortality  of  the 
winter,  spring,  and  summer  quarters  of  1862  (2839)  from  this  disease  was  alone 
in  excess  of  that  of  any  year  since  1848.  The  true  source  of  this  excess  of 
mortality  would  not  have  been  rightly  understood  except  by  the  careful  nosolo- 
gical and  etiological  distinction  of  the  forms  of  continued  fever  insisted  upon 
by  Dr.  Murchison.  The  mortality  from  scarlatina  was  but  a  little  below  that 
from  continued  fever  during  the  twelve  months — the  total  mortality  from  the 
former  malady  being  3437 ;  from  the  latter,  3463.  Next  in  order  of  mortality 
was  whooping-cough.  Continued  fever,  scarlatina,  and  whooping-cough  were 
the  chief  epidemic  affections  of  the  period  under  observation  in  the  metropolis. 
The  mortality  from  continued  fever  increased  to  a  maximum  in  the  second 
quarter  of  1862.  The  mortality  from  scarlatina  was  at  its  maximum  in  the  last 
quarter  of  1861,  then  decreased  throughout  the  two  succeeding  quarters,  but 
largely  increased  again  in  the  summer  quarter  of  1862.  The  mortality  from 
whooping-cough  was  greatest  in  the  first  quarter  of  1862.  Diphtheria  was  still 
largely  fatal,  having  occasioned  625  deaths.  Mr.  .Radcliffe  detailed  the  history 
of  the  outbreak  of  typhus  at  Preston,  in  Lancashire,  to  the  date  of  reading  the 
report :  he  dwelt  also  at  some  length  on  epizootic  diseases,  brought  together  the 
chief  accessible  information  on  epiphytics,  and  terminated  his  report  by  a  brief 
analysis  of  the  principal  contributions  to  epidemiological  literature  in  Great 
Britain  during  1861-62.  The  chief  diseases  prevalent  among  domesticated  ani- 
mals were  epizootic  pleuro-pneumonia,  and  the  vesicular  disease  of  the  mouth 
and  feet.  Scores  of  sheep  suffered  and  were  lost  from  filario  in  the  bronchial 
tubes  and  abomasum ;  there  were  several  local  but  very  fatal  outbreaks  of 
influenza  among  horses ;  and  an  outbreak  of  variola  ovina  occurred  in  Wilt- 
shire. The  history  of  the  latter  outbreak,  which  occasioned  great  alarm  at  the 
time,  will  be  imperfect  until  the  official  reports  are  published.  There  was  no 
special  disease  among  plants  during  the  year. — Medical  Times  and  Gazette, 
February  14,  1863. 

60.  Sir  David  Brewster  on  the  Characteristics  of  the  Age. — The  following 
extracts  from  the  address  delivered  at  the  opening  of  the  winter  session  of  Edin- 
burgh University  by  Sir  David  Brewster,  will  be  found  interesting:— 

Were  we  asked  to  characterize  the  age  in  which  we  live,  we  should  describe 
it  as  remarkable  for  its  love  of  the  mysterious  and  the  marvellous,  its  passion 
for  the  supernatural,  and  its  morbid  craving  for  what  the  eye  cannot  see,  nor 
the  ear  hear,  nor  the  judgment  comprehend.  I  do  not  allude  to  clairvoyance 
and  spirit-raising,  which  are  even  now  misleading  men  of  high  attainments,  but 
to  more  specious  extravagances  appealing  at  this  moment  to  our  faith,  and  more 
likely,  from  their  alleged  foundation  in  science,  to  captivate  the  young  and  the 
unwary.  These  speculations  have  been  long  working  in  the  public  mind,  fasci- 
nating us  occasionally  in  the  creations  of  the  poet,  and  investing  the  humblest 
observer  with  a  power  which  he  delights  to  exercise,  and  is  therefore  unwilling 
to  resign.  I  refer  to  the  so-called  science  of  physiognomy,  but  more  especially 
to  that  morbid  expansion  of  it  called  the  physiognomy  of  the  human  form,  which 
has  been  elaborated  in  Germany,  and  is  now  likely  to  obtain  possession  of  the 
English  mind.  The  fundamental  propositions  of  this  new  art  are,  "that  the 
outer  form  of  man  has  been  designed  on  purpose  to  represent  his  mental 
character,"  "that  the  invisible  is  revealed  in  the  visible,"  "that  the  body  is  the 

1  See  Dr.  Murchison's  recently  published  treatise  on  the  "Continued  Fevers  of 
Great  Britain"  (page  52),  for  an  account  of  this  epidemic. 


1863.J 


Miscellaneou 


525 


image  of  the  mind,"  and  that  every  man's  mental  nature  may  be  discovered  in 
his  external  form.  The  physiologist  who  has  taken  the  most  active  part  in 
advocating  these  opinions  is  Dr.  Carus,  of  Dresden,  Physician  to  the  late  King 
of  Saxony,  and  so  eminent  professionally  that  he  was  recently  elected  a  corres- 
ponding member  of  the  National  Institute  of  France.  Had  his  speculations 
remained  in  the  German  tongue,  I  should  not  have  ventured  to  bring  them  to 
your  knowledge.  They  have  been  adapted,  however,  and  extended,  both  by 
French  and  English  writers,  and  having  been  brought  prominently  forward,  and 
defended  and  amplified  in  the  most  religious,  conservative,  and  best  circulated 
quarterly  journal  of  the  day,  they  have  taken  an  aggressive  position  which  it 
becomes  a  public  duty  to  assail.  In  support  of  this  doctrine  of  symbols  in  the 
human  form,  as  it  is  called,  the  leading  argument  is  derived  from  the  nearly 
universal  assent  to  it  implied  in  the  practice  of  judging  of  men  by  their  personal 
appearance.  The  opinions  of  Sir  Thomas  Brown,  Addison,  Cowper,  Fielding, 
Southey,  and  others — men  quite  incapable  of  carrying  on  a  scientific  investiga- 
tion— are  all  marshalled  in  its  favour,  and  the  student  is  thus  prejudiced,  at  the 
commencement  of  his  inquiry,  by  the  authority  of  great  names.  A  second  argu- 
ment is  derived  from  the  occurrence  in  various  languages  of  such  expressions 
as  long-headed,  stiff-necked,  etc.,  which  are  supposed  to  establish  the  existence 
of  a  general  belief  in  the  correspondence,  not  only  of  mind  and  body,  but  of 
mind  and  shape.  In  want  of  any  other  arguments,  our  physiognomists  dogma- 
tically declare  that  the  expressions  of  rage,  or  grief,  or  fear,  have  been  "  divinely 
designed  on  purpose  that  the  inner  mind  may  be  known  to  those  who  watch  the 
outer  man."  We  know  very  little  of  the  true  inner  life  of  our  neighbours,  and 
we  should  not  like  that  our  neighbours  knew  much  more  of  our  own.  In  some 
persons  their  inner  life  appears  to  be  openly  and  injuriously  displayed.  In  others 
it  is  artfully,  wisely,  and  advantageously  concealed ;  and  frequently  it  is  hidden 
by  the  very  marks  which  are  supposed  to  display  it.  Of  the  individual  features 
which  are  assumed  to  be  most  symbolical  of  the  intellectual  and  moral  character, 
the  size  and  shape  of  the  head  is  one  of  the  most  important.  Without  any 
inductive  evidence  of  this  symbolism,  we  are  asked  to  believe  that  large  brains 
and  ample  foreheads  are  found  in  certain  individuals  of  high  intellectual  capa- 
city ;  but  we  never  hear  of  the  small  brains  and  narrow  brows  of  men  of  equal 
talent,  or  of  the  opposite  class  of  imbeciles  who  have  heads  and  brains  like  those 
of  their  neighbours.  In  this  new  physiognomy,  a  head  large  in  the  mid-region 
indicates  a  predominance  of  the  feelings  over  the  other  faculties.  A  proneness 
to  superstition  and  fanaticism  is  shown  by  a  little  increase  in  the  elevation  ;  and 
a  head  large  behind  evinces  practical  ability,  and,  as  Dr.  Carus  says,  charac- 
terizes a  race  which  will  give  birth  to  great  historic  names  !  Small  heads,  how- 
ever, are  not  to  be  despised.  They  indicate  talent,  but  not  genius ;  while  very 
small  ones  belong,  he  says,  to  the  excitable  class  from  whom  "  a  great  part  of 
the  misery  of  society  arises."  In  the  varying  expressions  of  the  human  face, 
physiognomists  find  a  better  support  for  their  views.  That  the  emotions  of  the 
past  and  the  preseflt  leave  permanent  traces  on  the  human  countenance  is, 
doubtless,  true,  and  to  this  extent  we  are  all  physiognomists,  often  very  pre- 
sumptuous ones,  and,  excepting  accidental  coincidences,  always  in  the  wrong, 
when  we  infer  from  any  external  appearance  the  character  and  disposition  of 
our  neighbour.  In  every  class  of  society  we  encounter  faces  which  we  instinc- 
tively shun,  and  others  to  which  we  as  instinctively  cling.  But  how  fre- 
quently have  we  found  our  estimates  to  be  false  ?  The  repulsive  aspect  has 
proved  to  be  the  result  of  physical  suffering,  of  domestic  disquiet,  or  of  ruined 
fortunes;  and,  under  the  bland  and  smiling  countenance,  a  heart  deceitful 
and  vindictive,  and  "  desperately  wicked,"  has  often  been  found  concealed. 
The  countenance,  too,  which  in  manhood  was  noble  and  benign,,  we  may  have 
seen  scarred  in  the  battle  of  life,  and  furrowed  with  the  deep  lines  which 
the  baseness  of  friends  and  the  injustice  of  the  world  never  fail  to  imprint. 
And  when  the  manly  aspirant  after  wealth  or  fame  has  been  cruelly  worsted  in 
the  race  of  ambition,  and  has  displayed  on  the  outer  man  the  impress  of  the 
emotions  which  disturbed  him,  how  often  have  we  seen  him  under  altered  cir- 
cumstances resuming  the  joyous  expression  of  his  youth,  which  misfortune  has 
but  temporarily  disguised.    These  views  will  acquire  additional  support  if  we 


526 


Progress  of  the  Medical  Sciences. 


[April 


examine  large  groups  of  individuals  living  under  the  same  influences,  and  there- 
fore likely  to  have  the  same  external  development.  In  the  haunts  of  vice,  within 
the  precincts  of  the  gaol,  in  the  stock  exchange,  and  in  the  marts  of  commerce, 
we  shall  find  the  same  variety  of  form  and  expression,  and  the  same  difficulty  in 
discovering  vice  or  virtue  in  the  outer  man.  The  criminal  in  the  dock,  charged 
with  murder,  will  often  bear  an  honourable  comparison  with  the  functionary  who 
prosecutes  him,  the  advocate  who  defends  him,  or  the  judge  who  tries  him.  In 
descending  to  individual  features,  the  eyes,  nose,  mouth,  chin,  ears,  and  even  the 
hair,  are  said  to  instruct  us  in  the  character  of  our  neighbour;  and  the  neck, 
trunk,  hands,  and  feet  become  monitors  in  the  same  school.  .  Of  all  these 
teachers,  the  eye  and  the  nose  are  the  most  accomplished.  Dr.  Carus  tells  us 
that  the  eye  speaks  to  us  in  its  colours  and  in  its  lustre;  that  yellow  indicates 
genius;  dark  blue,  effeminacy;  light  blue  and  gray,  activity;  green,  courage; 
and  hazel,  mental  depth ;  and  he  pronounces  this  organ  to  be  so  richly  symbolical 
that,  instead  of  saying  that  the  "  style  is  the  man,"  we  might  more  justly  say 
that  the  "  eye  is  the  man."  In  refutation  of  such  assumptions,  we  assert  that 
there  is  no  expression  whatever  in  the  human  eyeball,  consisting  of  a  transpa- 
rent cornea,  a  coloured  iris,  with  the  pupil  in  its  centre,  and  the  white  sclerotic 
coat.  You  may  as  hopefully  search  for  expression  in  a  watch-glass  as  in  the 
cornea,  as  hopefully  in  a  coloured  wafer  with  a  hole  in  the  centre  as  in  the  iris, 
and  as  well  in  a  piece  of  white  kid  leather  as  in  the  sclerotic  coat.  Such  is  a 
brief  notice  of  the  new  science  which  is  to  maintain  the  waning  excitement  of 
more  dangerous  and  offensive  speculations.  The  talents  and  eloquence  of  its 
German  and  English  expositors  may  obtain  for  it  a  temporary  popularity ;  and 
philosophers,  male  and  female,  will  doubtless  study  and  apply  its  symbols. — 
Brit.  Med.  Journ.,  Nov.  29,  1862. 


1863.] 


527 


AMERICAN  INTELLIGENCE. 

ORIGINAL  COMMUNICATIONS. 

Circular  from  the  Burgeon- General  U.  S.  A. — [We  take  pleasure  in 
calling  attention  to  the  following  circular,  which  we  take  for  granted  is  all 
that  is  necessary  to  secure  the  cordial  and  general  co-operation  of  the 
profession  in  the  collection  of  the  information  desired  by  the  Surgeon- 
General.  The  facts  thus  accumulated  cannot  fail  to  contribute  to  the 
advancement  of  our  science,  and  be  most  useful  to  the  profession  : — ] 

Surgeon-General's  Office, 
Washington  City,  D.  C,  Feb.  20, 1863. 

The  Surgeon-General  would  remind  the  medical  profession  that,  some 
months  since,  a  medical  officer  was  detailed  by  the  department  to  prepare 
the  surgical  history  of  the  rebellion.  It  is  intended  that  this  history  shall 
embrace,  among  other  topics,  the  collected  results  of  the  gunshot  injuries 
of  the  war,  and  of  the  operations  performed  for  their  relief. 

Many  facts,  bearing  on  these  subjects,  can  be  obtained  by  an  examination 
of  the  returns  of  the  various  military  hospitals  ;  and  explicit  orders  have 
been  issued  to  the  surgeons  in  charge  as  to  the  manner  of  reporting.  Yet 
it  is  found,  practically,  that  the  results  of  all  cases  cannot  be  included  in 
these  reports. 

In  every  depot  of  wounded,  and  after  every  action,  there  exists  a  large 
class  of  injured  men,  who,  in  various  stages  of  convalescence,  pass  from 
the  observation  and  treatment  of  the  military  surgeon,  and  are  lost  sight 
of  by  the  medical  department.  These  patients  are  those  who  are  either 
furloughed  or  discharged  the  service  by  military  authority  before  their  treat- 
ment is  entirely  terminated.  Under  such  circumstances,  all  past  records  of 
these  cases  are  rendered  valueless  from  the  absence  of  a  positive  knowledge 
of  their  results. 

To  remedy  this  evil  the  Surgeon-General  appeals  to  the  profession  of  the 
country,  and  solicits  their  co-operation.  He  would  ask  every  physician 
and  surgeon  who  may  be  called  upon  to  treat  any  officer  or  soldier  wounded 
in  service,  carefully  to  note  the  results  of  the  case,  to  record  his  observa- 
tions, and,  when  the  case  shall  have  terminated,  to  transmit  a  copy  of  his 
observations  to  the  Surgeon-General's  office. 

The  following  form  is  suggested : — 


Form.  Date  of  Communication. 

Character  of  Injury.  Name  and  Address  of  Physician  forwarding  it. 


Where 
wounded 
and  date. 

To  what 
hospital 
trans- 
ported. 

What  ope- 
rations, 
&c,  per- 
formed. 

By  whom 
per- 
formed. 

Date  of 
furlough 
or 

discharge. 

Present  condition  of 
patients.  Account 
of  case.  Treatment, 
&c.  Result. 

Patient's  name  and  age. 
"  rank. 

"    regiment  &  Co. 
"    postal  address. 

528 


American  Intelligence. 


[April 


In  all  cases  of  recovery  after  excisions  of  bone,  the  amount  and  cha- 
racter of  the  movements  executed  by  the  patient,  with  the  injured  limb, 
should  be  accurately  described.  Where  amputation  has  been  practised,  the 
character  of  the  stump  should  be  noted,  especially  when  the  operation  has 
been  performed  through  an  articulation.  In  cases  of  compound  fracture 
the  point  of  fracture  should  be  stated,  as  also  the  degree  of  efficiency  of  the 
limb  remaining  after  treatment.  In  compound  fractures  of  the  femur  the 
amount  of  shortening  should  be  measured,  and  the  strength  and  usefulness 
of  the  limb  described.  In  those  patients  in  whom  injuries  of  the  skull 
have  occurred,  or  upon  whom  the  trephine  has  been  applied,  the  mental  and 
physical  conditions  should  alike  be  dwelt  upon. 

In  thus  placing  before  the  profession  the  objects  he  desires  to  obtain,  the 
Surgeon-General  trusts  that  he  will  meet  with  active  co-operation.  By  the 
means  above  indicated  much  information  that  is  valuable  may  be  collected, 
and  the  interests  of  the  science  of  surgery  materially  advanced. 

W.  A.  Hammond, 
Surgeon- General  U.  S.  A. 

Medical  journals  will  please  copy. 


DOMESTIC  SUMMARY. 

Double  Vision  with  each  and  both  Eyes. — Dr.  G.  A.  Bethune  records  (Bos- 
ton Medical  and  Surgical  Journal,  February  12,  1863),  the  following  example 
of  this  remarkable  disturbance  of  vision: — 

"  Mrs.  ■  ,  aged  37,  the  wife  of  a  physician,  and  who  ha«l  formerly  taught 

in  one  of  the  highest  of  our  private  schools,  consulted  me  first  c>n  the  10th  of 
March,  1862.  Naturally  far-sighted,  and  without  previous  trouble  in  the  eyes, 
eighteen  months  ago,  after  unusual  exertion  in  studying,  she  was  seized  with 
double  vision  with  each  and  both  eyes.  She  suffers  no  pain,  photophobia,  or 
other  subjective  symptom.  This  diplopia  does  not  extend  to  very  near  objects, 
the  nearest  point  being  from  four  to  five  feet.  The  new  moon  she  describes  as 
seeing  with  four  horns.  The  false  image  seems  always  to  the  left,  except  in  the 
case  of  horizontal  lines,  as,  for  instance,  a  telegraph  wire,  when  it  appears  below. 
The  appearances  are  the  same  with  either  eye  covered.  By  bending  the  head, 
she  thinks  to  the  left,  the  two  images  coincide.  She  thinks  there  has  been  no 
variation  in  the  double  vision  since  she  first  observed  it,  when  the  circumstances 
are  the  same.  She  observes  it  more  when  looking  towards  the  sky,  and  in  clear 
light,  than  when  the  light  is  weaker. 

"  She  is  rather  a  delicate-looking  person,  though  her  general  health  is  good. 
Her  hands  and  feet  are  apt  to  be  cold.  About  six  months  ago  she  was  attacked 
with  tinnitus  of  both  ears,  which  still  continues. 

"  On  examination,  the  only  abnormal  appearance  in  the  eyes  is  a  little  tinea 
ciliaris.  She  was  advised  to  rest  the  eyes,  to  apply  a  lotion  of  acetate  of  lead 
to  them,  and  a  stimulating  lotion  to  the  spine.  To  take  sherry  wine,  and  exer- 
cise in  the  open  air  up  to  her  strength. 

"Jan.  17,  1863. — Was  again  seen  to-day.  No  change  in  eyes.  Other  things 
as  above,  except  that  the  tinnitus  has  diminished.  The  left  pupil  was  dilated 
with  atropine,  and  the  eye  examined  with  Burow's  ophthalmoscope.  Nothing 
abnormal  seen.  Two  repetitions  of  this  examination,  on  different  days,  were 
made  with  the  same  result." 

Chestnut  Leaves  in  Whooping-Cough. — Mr.  Geokge  C.  Close,  of  Brooklyn, 
N.  Y.,  speaks  highly  of  the  efficacy  of  the  chestnut  leaves  in  whooping-cough. 
He  states  that  by  the  recommendation  of  a  physician  of  New  York  he  gave  to 


1863.] 


Domestic  Summary. 


529 


a  child  with  incipient  whooping-cough,  an  infusion  of  the  leaves  of  the  chestnut, 
made  with  boiling  water  and  sweetened  with  sugar.  She  drank  it  freely  and 
without  objection,  the  taste  not  being  unpleasant.  The  cough,  which  had  con- 
tinued for  two  weeks,  and  was  evidently  growing  worse  previous  to  giving  the 
remedy,  was  immediately  relieved,  and  after  two  or  three  days  ceased  entirely, 
and  has  not  returned  though  several  months  have  passed. 

Since  making  this  trial,  when  asked  by  customers,  "What  is  good  for 
whooping-cough?"  he  has  advised  them,  if  they  had  no  physician  in  attend- 
ance, to  try  the  leaves.  In  several  instances  after  trying  them,  they  have 
reported  that  "  they  acted  like  a  charm,"  and  gave  immediate  and  great  relief. 

"  I  have  also  heard,"  he  says,  "  of  cases  of  adults,  who  were  affected  with  that 
kind  of  spasmodic  cough  which  is  sometimes  caused  by  some  (perhaps  slight) 
source  of  irritation  in  the  throat,  being  immediately  relieved  by  the  same  remedy. 

"  As  I  have,  occasionally,  calls  for  chestnut  leaves,  I  asked  a  person  who 
applied  for  them  a  few  days  since,  for  what  purpose  he  used  them  ?  He  replied, 
as  a  remedy  for  whooping-cough,  for  which  they  were  very  good,  and  that  they 
often  relieved  other  kinds  of  cough  also.  This  shows  that  their  use  is  becoming 
somewhat  popular  as  a  domestic  remedy. 

"  A  very  extensive  use  of  an  article  is  required,  however,  to  test  its  real  value 
as  a  remedy,  and  I  only  present  the  foregoing  facts  as  warranting,  in  my  judg- 
ment, farther  trials  of  the  leaves." — Proceed.  Am.  Pharm.  Assoc.,  1862,  and 
Ap>.  Joum.  Pharm.,  Jan.  1863. 

Active  Principles  of  Veratrum  Viride. — Mr.  G.  J.  Scattergood,  of  Phila- 
delphia, has  isolated  the  active  principles  of  the  root  of  veratrum  viride,  and 
tried  their  effects  separately  on  the  animal  system,  in  order  to  ascertain  to  which 
of  these  principles  the  sedative  action  of  the  plant  is  due. 

These  principles  he  says,  "  appear  to  be,  Firstly :  Yeratria.  Secondly  :  An 
alcoholic  resin. 

"  They  are  obtained  in  the  following  manner :  The  finely  ground  root  is  ex- 
hausted by  the  smallest  possible  quantity  of  strong  alcohol.  This  tincture  is 
slowly  poured  into  a  larger  bulk  of  water,  and  the  mixture  exposed  to  a  gentle 
heat  to  drive  off  the  alcohol.  When  this  is  done,  the  liquid  is  raised  to  the 
boiling  point,  and  immediately  filtered.  The  resin  remains  in  the  filter,  while 
the  veratria  which  appears  to  exist  in  this  drug  in  a  form  soluble  in  boiling 
water,  is  found  in  the  filtrate,  from  which  it  may  be  precipitated  by  the  addition 
of  ammonia.  The  alkaloid  thus  obtained  is  contaminated  by  another  substance 
of  a  similar  nature  to  veratria,  but  insoluble  in  ether,  from  which  it  may  be 
separated  by  treatment  with  that  menstruum,  the  veratria  being  left  upon  its 
evaporation,  of  a  yellowish  color — requiring  further  purification.  The  other 
substance  remains  in  the  residue,  and  may  be  extracted  from  it  and  obtained  in 
the  form  of  a  brownish  adhesive  mass,  by  the  action  of  strong  alcohol.  It  is 
somewhat  soluble  in  water,  but  precipitated  from  its  aqueous  solution  by 
muriatic  acid.  This  solution  froths  considerably  when  shaken :  Sulphuric  acid 
is  colored  orange  yellow  by  it.  Muriatic  acid  a  delicate  red.  It  appears  to 
be  a  compound  of  ammonia  with  one  of  the  organic  acids  derived  from  the  root. 
Its  medicinal  effects  were  not  examined. 

"The  medicinal  properties  of  the  two  active  principles  before  alluded  to  have 
been  tested  principally  by  experiments  upon  dogs.  In  this  part  of  the  examina- 
tion I  have  been  very  much  assisted  by  Dr.  Saml.  E.  Percy,  of  New  York,  who 
has  kindly  tried  several  experiments  at  my  request,  and  furnished  me  with  a 
detailed  account  of  them." 

These  experiments  made  upon  dogs,  "  indicate  a  very  great  similarity  in  the 
general  therapeutic  properties  of  the  alkaloid  and  the  resin.  In  each  of  these 
cases  a  great  increase  of  the  saliva,  prolonged  emesis,  general  prostration  and 
reduction  of  the  pulse  were  produced  ;  and  in  every  case,  but  one,  dilatation  of 
the  pupils  also.  But  it  will  be  noticed  that  this  reduction  of  the  pulse  was 
much  greater  in  those  cases  when  the  resin  had  been  administered,  than  in  that 
in  which  the  alkaloid  was  given.  In  the  former  being  from  165  to  41 ;  from  144 
to  40  ;  and  from  140  to  70 ;  while  in  the  latter  it  was  reduced  from  150  only  to 
112.  In  another  instance  in  which  the  same  alkaloid  prepared  by  Dr.  Percy, 
No.  XC— April  1863.  34 


530 


American  Intelligence. 


[April 


by  purifying  the  commercial  veratria,  was  administered  in  the  dose  of  one-third 
of  a  grain,  to  a  dog  weighing  25  lbs.,  the  pulse  was  likewise  only  moderately 
reduced,  viz :  from  132  to  100,  the  attendant  effects  being  very  much  the  same 
as  those  just  described.  . 

"Judging  from  these  parallel  experiments,  and  from  the  fact  that  the  resin 
exists  in  very  much  larger  quantity,  than  the  alkaloid,  in  this  drug,  it  would 
appear  that  the  sedative  action  of  veratrum  viride  is  due  in  greater  degree  to 
the  alcoholic  resin  it  contains  than  to  its  veratria. 

"  I  may  add  that  the  action  of  the  resin  upon  the  human  system  produces 
results  very  similar  to  those  just  described.  On  the  14th  inst.,  at  5.15  P.  M., 
I  took  two  grains  of  the  alcoholic  resin.  Pulse  80.  At  6.45,  its  effects  were 
first  apparent  in  slight  spasmodic  contractions  of  the  muscles  of  the  leg — these 
soon  passed  off  and  were  not  afterwards  noticed.  At  7.45,  free  vomiting  began, 
accompanied  with  an  increased  flow  of  saliva  and  general  perspiration ;  the 
vomiting  continued  at  intervals  for  upwards  of  an  hour,  and  until  considerable 
bile  had  been  thrown  up  ;  and  was  followed  by  painful  retching :  at  8.45,  pulse 
60 — by  this  time  the  feeling  of  warmth  had  been  succeeded  by  general  coldness 
of  the  body  and  loss  of  strength.  At  9.15,  pulse  55.  At  9.30  fell  asleep.  The 
only  effects  observed  in  the  morning  were  general  weakness,  and  a  somewhat 
depressed  pulse.  No  tingling  of  the  skin  so  frequently  occasioned  by  veratria, 
nor  catharsis,  was  produced. 

"  The  resin  thus  experimented  with  is  of  a  soft  consistence,  and  of  a  mild,  oHy, 
though  nauseous  taste  at  first,  but  leaving  after  some  time  a  somewhat  acrid 
sensation  in  the  fauces.  It  is  of  a  brownish-black  color.  It  yields  to  ether  its 
more  oily  portion,  about  one-quarter  its  weight, — the  remainder,  insoluble  in 
that  menstruum,  is  left  of  a  harder  and  more  friable  consistence.  In  order  to 
remove  any  suspicion  that  the  medicinal  action  of  the  resin  was  due  to  a  minute 
quantity  of  the  alkaloid  remaining  in  it,  I  administered  three-quarters  of  a  grain 
of  the  residue  left  after  treating  the  alcoholic  resin  with  ether  (which  would 
have  removed  any  veratria  if  present)  to  a  half-grown  cat.  Its  effects  were 
very  similar  to  those  of  the  alcoholic  resin  before  mentioned,  vomiting,  dilata- 
tion of  the  pupils,  slight  spasms  of  the  muscles,  slow  breathing,  and  reduction  of 
the  pulse- from  the  neighbourhood  of  100  to  42,  were  produced  in'the  course  of 
a  few  hours. 

"  The  quantity  of  resin  obtained  from  1  lb.  avoir,  of  the  dried  root  of  veratrum 
viride  may  be  stated  at  about  300  grains — of  veratria  about  30  grains.  From 
its  reaction  with  sulphuric  acid,  the  tinct.  iodine  test,  and  a  solution  of  the 
iodo-hydrargyrate  of  potassium,  I  am  of  the  opinion  that  it  may  perhaps  be  an 
altered  form  of  veratria.  I  have  not  succeeded  in  detecting  the  presence  of 
sabadillia.  The  existence  of  jervia  in  the  filtrate  from  which  the  veratria  was 
precipitated,  was  thought  probable  from  the  white  precipitate  which  was  pro- 
duced in  it  upon  the  addition  of  sulphuric  acid." — Proceed.  Am.  Pharm.  Assoc., 
1862,  and  Am.  Joum.  Pharm.,  Jan.  1863. 

Operation  for  Compression  of  the  Spinal  Cord. — Dr.  H.  A.  Pottek,  of  Ge- 
neva, N.  Y.,  relates  ( American  Med.  Times,  Jan.  10, 1863)  the  following  case 
of  this : — 

"A.  M.  Salsbury,  of  Phelps,  Ontario  County,  New  York,  while  engaged  in 
gathering  walnuts,  in  October,  1859,  fell  from  a  tree  a  distance  of  twenty  feet, 
and  fractured  certain  vertebras  in  the  inferior  cervical  region.  Three  days  after 
the  accident  I  was  called  in  consultation.  The  patient  was  perfectly  conscious, 
but  was  unable  to  move  any  part  of  the  body  or  extremities,  except  the  hands, 
which  he  could  slightly  raise,  but  which  would  fall  upon  reaching  a  certain 
point,  without  the  least  control  of  the  will  over  them.  Sensation  was  as  imper- 
fect as  the  motion.  The  patient  being  a  fleshy  man,  it  was  difficult  to  determine 
the  exact  point  of  injury. 

"It  was  decided  I  should  operate,  which  I  did,  October  9,  1859.  I  found  the 
spinous  process  of  the  sixth  vertebra  fractured  and  displaced,  and  the  arch  of 
the  fifth  crushed  in  upon  the  spinal  cord,  nearly  separating  it  longitudinally. 
With  some  difficulty  I  removed  all  that  portion  comprised  in  the  lamina  and 
spinous  process  of  the  fifth  and  the  spinous  process  of  the  sixth  cervical  ver- 


1863.] 


Domestic  Summary. 


531 


tebrte.  The  sheath  of  the  spinal  cord  was  entire,  but,  as  before  stated,  the  cord 
itself  was  much  injured. 

"I  did  not  see  the  patient  again  until  the  following  January,  at  which  time  the 
wound  was  nearly  healed,  and  he  was  as  comfortable  as  could  be  expected ;  he 
could  sit  in  an  easy  chair,  could  readily  move  his  head,  and  could  converse  as 
freely  as  any  one.  He  had  gained  very  little  from  the  operation — sensation  and 
motion  being  as  imperfect  as  when  first  injured,  except  that  he  could  use  his 
left  hand  a  little  more  freely  than  before.  He  remained  in  this  unhappy  condi- 
tion until  November  29, 1862,  when  I  was  again  called  to  see  if  something  might 
be  done  to  relieve  him.  During  the  past  three  years  there  had  been  some  spas- 
modic action  of  the  lower  extremities,  and  thinking  that  some  compression 
might  still  exist — which,  from  the  stout  and  fleshy  condition  of  the  neck,  had 
escaped  detection  in  my  first  examination — and  as  the  situation  of  the  patient 
could  not  be  made  worse,  I  determined  upon  another  operation,  which  was  made 
in  the  presence  and  with  the  assistance  of  Dr.  Dox,  of  Geneva,  and  Dr.  Car- 
penter, of  Phelps. 

"  I  removed  the  fourth,  sixth,  and  seventh  cervical  vertebras,  which  left  the 
portion  of  the  spinal  cord  covered  by  the  four  inferior  cervical  vetebras  entirely 
exposed.  The  cord  had  not  united,  but  at  the  point  of  the  first  operation  it 
was  well  protected  by  a  thick  substance,  resembling  the  coat  of  a  large  artery. 
At  least  an  inch  of  the  superior  portion  of  the  exposed  part  was  much  flattened 
and  thinned,  but  the  sheath  was  entire.  At  the  connection  of  the  first  dorsal 
vertebra  the  cord  was  full,  and,  to  all  appearance,  in  a  normal  condition.  There 
was  no  pulsation  at  any  point  exposed,  but  there  had  been  at  the  first  operation ; 
and,  in  my  judgment,  the  pulsation  of  the  cord  will  determine  very  correctly  the 
diagnosis  as  to  the  extent  of  the  injury.  In  two  cases  upon  which  I  had  pre- 
viously operated,  the  cord  could  not  be  only  felt  but  the  pulsation  could  be  dis- 
tinctly seen.  In  both  cases  it  was  simply  the  yoking  in,  as  it  were,  of  the  arch 
of  the  vertebra  upon  the  spinal  cord — the  cord  not  being  in  the  least  separated. 
The  first  case  was  of  five  months'  standing,  and  was  the  most  perfect  instance 
of  paralysis  and  loss  of  sensation  I  have  ever  seen.  A  report  of  the  same  may 
be  found  in  the  Journal  of  Medicine  and  Collat.  Sciences  for  March',  1844.  It 
was,  I  believe,  before  the  time  of  chloroform,  and  sensation  returned  instanta- 
neously upon  removing  the  compression,  and  a  perfect  recovery  was  effected. 
The  other  case  I  did  not  report.  The  patient  was  a  coloured  man  by  the  name 
of  Susey.  The  operation  was  performed  at  Geneva,  New  York.  I  removed 
the  posterior  portion  of  the  three  inferior  cervical  vertebras,  and  found  the  cord 
had  simply  been  pressed  against  the  body  of  the  spinal  column ;  the  cord  was 
not  separated,  and  pulsated  freely.  I  had  great  hopes  of  his  recovery,  but  he 
died  the  fourth  day.  An  autopsy  showed  fracture  of  the  left  parietal  and  occi- 
pital bone.  A  large  clot  of  blood  was  also  found  around  the  foramen  magnum, 
which  was  beyond  doubt  the  cause  of  his  death. 

il  The  last  operation  upon  Mr.  Salsbury  has  as  yet  proved  of  no  benefit  to  him, 
and  it  probably  never  will,  as  nearly  all  connection  with  the  brain  is  obliterated. 

"  There  are  two  points  I  wish  to  call  the  attention  of  the  profession  to  in  con- 
nection with  this  class  of  injuries.  The  first  is,  that,  in  all  cases  which  have 
come  under  my  notice,  and  I  have  seen  eight,  when  blood  is  taken  from  a  vein 
of  the  arm  it  is  arterial.  This  being  true,  the  change  from  arterial  to  venous 
blood  must  be  dependent  upon  the  cerebro-spinal  action  of  the  nervous  system, 
and  it  is  not  absolutely  necessary  for  the  change  to  take  place  in  the  passage 
through  the  system. 

"  The  second  point  is,  that,  immediately  after  the  receipt  of  the  injury,  the 
patient  begins  to  lose  flesh,  and  during  the  first  few  weeks  becomes  much  ema- 
ciated. Arriving  at  a  certain  point  the  recuperative  powers  of  the  system  seem 
to  rally,  and  nutrition  appears  perfect — the  patients  gain  flesh  in  about  the  same 
proportion  as  it  was  lost. 

"  Why  is  this,  and  what  is  the  cause  of  the  suspension  and  restoration  of  nutri- 
tion ?  My  own  opinion  is,  that  suspension  of  nutrition  is  in  consequence  of  the 
toss  of  the  nervous  action. 

"  But  what  restores  it  ?  It  cannot  come  from  its  original  source,  for  the  cause 
is  not  removed,  and  there  is  no  sensation  or  motion  below  the  injury,  and  no 
direct  communication  with  the  brain." 


532 


American  Intelligence, 


[April 


Extract  from  the  Annual  Report  of  tlie  Surg  eon- General,  U.  S.  A. — "  During 
the  past  year  the  health  of  the  troops  has  been  remarkably  excellent.  No  epi- 
demics of  any  severity  have  appeared  among  them,  and  those  diseases  which 
affect  men  in  camp  have  been  kept  at  a  low  minimum.  Scurvy  has  been  almost 
entirely  prevented,  and  yellow  fever,  from  which  much  was  feared,  has  had  but 
few  victims.  This  immunity  is  due  to  the  excellent  hygienic  arrangements 
instituted,  and  to  the  cordial  manner  in  which  generals  in  commands  have 
cooperated  with  the  proper  authorities. 

"  In  an  army  of  the  size  of  that  now  maintained  by  the  United  States,  it  was 
of  course  to  be  expected  that  the  absolute  number  of  sick  would  be  very  large, 
and  the  important  battles  which  have  been  fought  have  thrown  a  large  number 
of  wounded  on  the  care  of  the  department.  At  present  the  total  number  under 
the  charge  of  officers  of  the  medical  department  is  not  short  of  70,000,  and 
immediately  after  the  battle  of  Antietam  it  was  over  90,000.  That  this  large 
number  could  be  provided  for  without  some  cases  of  unnecessary  suffering 
occurring,  would  perhaps  be  too  much  to  expect ;  but  I  must  commend  the 
medical  corps,  both  of  the  regular  and  volunteer  service,  for  the  faithful  and 
efficient  manner  in  which  their  duties  have  been  performed.  In  the  discharge 
of  their  duties  medical  officers  have  been  very  much  aided  by  the  contributions 
of  the  people  of  the  country,  and  by  the  efficient  cooperation  of  the  Sanitary 
Commissioa  and  Relief  Associations. 

"  In  addition  to  providing  the  sick  and  wounded  with  medical  attendance  and 
medicines,  much  has  been  done  by  the  department  in  furnishing  food,  clothing, 
and  comforts  of  various  kinds.  From  much  observation,  both  at  home  and 
abroad,  and  from  the  concurrent  testimony  of  distinguished  foreign  medical 
officers,  I  am  satisfied  that  never  before  were  the  sick  and  wounded  of  an  army 
so  well  cared  for  as  are  those  who  have  suffered  for  their  country  in  the  present 
rebellion.    The  hospitals,  I  take  pride  in  saying,  are  a  credit  to  the  nation. 

"Before  the  several  medical  boards  in  session  during  the  year  (from  July  1st, 
1861,  to  June  30th,  1862),  a  large  number  of  applicants  for  appointment  in  the 
medical  staff  of  the  army  were  invited  by  the  Secretary  of  War.  Of  these, 
sixty-six  candidates  duly  presented  themselves.  Thirty- three  of  this  number 
were  approved,  and  five  rejected;  the  remaining  twenty-eight  withdrew,  one  on 
account  of  physical  disqualification.  Before  the  same  boards,  eleven  assistant 
surgeons  were  examined  for  promotion  of  whom  nine  were  found  qualified,  and 
two  not  considered  as  coming  up  to  the  standard  of  merit  required.  In  the 
examination  by  these  boards,  the  standard  of  attainments  required  for  success 
was  much  lowered,  the  Board  in  New  York  being  ordered  to  examine  two  can- 
didates each  day  for  the  regular  army,  while  the  examination  of  candidates  for 
the  appointment  of  surgeon  of  brigade  became  little  more  than  a  farce.  Since 
the  1st  of  June  last,  however,  the  standard  of  examination  has  been  raised,  and 
the  gentlemen  now  entering  the  medical  staff  have  been  found  fully  competent 
to  undertake  the  important  trust  with  which  they  are  charged. 

"  The  breaking  out  of  the  rebellion  found  the  United  States  Army  with  a 
medical  department  arranged  for  a  peace  establishment  of  15,000  men.  #  Expe- 
rience soon  demonstrated  the  fact,  that,  however  efficient  its  officers  might  be, 
the  organization  was  such  as  to  ill  adapt  it  to  the  necessities  of  a  large  force  in 
time  of  war.  Partial  progress  in  the  right  direction  was  made  by  Congress  in 
increasing  the  rank  of  the  surgeon-general,  adding  a  limited  inspecting  corps, 
and  increasing  the  number  of  surgeons,  assistant  surgeons,  medical  cadets,  and 
hospital  stewards.  The  department  was  also  placed  on  a  more  independent 
footing,  and  its  whole  status  elevated.  But  there  are  still  other  measures, 
which,  if  adopted,  cannot  fail  to  add  to  the  efficiency  of  the  department,  and 
these  I  desire  to  urge  through  you  on  the  attention  of  Congress. 

u  First  among  these  is  the  establishment  of  a  permanent  hospital  and  ambu- 
lance corps,  composed  of  men  specially  enlisted  for  duty  in  the  medical  depart- 
ment, and  properly  officered,  who  shall  be  required  to  perform  the  duties  of 
nurses  in  the  hospitals,  and  to  attend  to  the  service  of  the  ambulances  in  the 
field.  By  the  establishment  of  this  corps  several  thousand  soldiers,  now  de- 
tached as  nurses,  cooks,  <fec,  would  be  returned  to  duty  with  their  regiments, 
and  the  expense  now  incurred  by  the  necessary  employment  of  contract  nurses 


1863.] 


Domestic  Summary. 


533 


obviated.  A  corps  formed  upon  the  basis  of  two  men  to  each  company  in  ser- 
vice, organized  into  companies  of  100  privates,  with  one  Captain,  two  Lieuten- 
ants, four  Sergeants  and  eight  Corporals  to  each  company,  would  relieve  the 
line  of  the  army  from  all  details  for  the  medical  department,  and  enable  the  de- 
partment to  render  far  more  efficient  services  to  the  sick  and  wounded  than  it 
is  capable  of  affording  under  the  present  system.  The  necessity  of  such  a  corps 
has  been  recognized  in  all  European  armies,  and  I  am  able  to  speak  from  per- 
sonal observation  of  the  great  advantages  to  be  derived  from  it. 

"  I  regard  an  increase  of  the  medical  corps,  both  of  the  regular  and  volunteer 
forces,  as  absolutely  necessary.  The  law  of  Congress,  approved  July  2d,  1862, 
provides  sufficiently,  except  for  cavalry  and  artillery  regiments,  for  the  want  of 
troops  in  the  field,  but  the  service  in  hospitals  has  to  be  filled  to  a  great  extent 
by  the  employment  of  contract  physicians.  I  therefore  recommend  that  the 
medical  corps  of  the  regular  army  be  increased  by  twenty  surgeons  and  forty 
assistant  surgeons,  and  the  staff  corps  of  volunteer  medical  officers  by  fifty  sur- 
geons and  two  hundred  and  fifty  assistant  surgeons.  This  last  corps  now  con- 
sists of  two  hundred  surgeons  and  a  hundred  and  twenty  assistant  surgeons. 
The  cavalry  and  artillery  organization  requires  medical  officers  as  much  as 
infantry.  The  omission  on  the  part  of  Congress  should  be  supplied  ;  a  surgeon 
and  two  assistant  surgeons  should  be  authorized  for  each  regiment  of  cavalry, 
and  for  each  regiment  of  heavy  artillery,  and  an  assistant  surgeon  for  each  light- 
battery. 

"  Under  the  first  section  of  the  act  of  June  30th,  1834,  assistant  surgeons  of 
the  regular  army  must  have  served  five  years  before  being  eligible  for  promotion 
as  surgeon.  On  the  1st  of  November  there  were  but  six  assistant  surgeons  in 
the  army  who  had  served  five  years.  The  effect  of  this  law  will  be  to  prevent 
the  filling  of  vacancies  which  may  occur  in  the  grade  of  surgeon,  and  I*there- 
fore  recommend  that  so  much  of  said  section  as  requires  assistant  surgeons  to 
serve  five  years  as  such,  before  being  eligible  to  Surgeoncies,  be  repealed. 

"  The  number  of  medical  cadets  is  altogether  too  small  for  the  necessities  of 
the  service.  I  therefore  recommend  that  authority  be  given  to  appoint  as  many 
as  may  be  required,  in  accordance  with  existing  laws  on  the  subject. 

"  The  institution  of  a  medical  inspecting  corps  has  been  productive  of  excel- 
lent results.  The  number  of  inspectors  authorized  is,  however,  too  limited  to 
enable  the  service  to  be  as  efficiently  performed  as  is  desirable.  I  therefore 
recommend  that  two  inspectors  general  and  eight  inspectors  be  added  to  the 
present  organization.  The  authorization  of  an  additional  assistant  surgeon- 
general  would  also  be  a  measure  of  great  propriety. 

"  Considerable  progress  has  been  made  in  the  establishment  of  an  army  medi- 
cal museum.  The  advantages  to  the  service  and  to  science  from  such  an 
institution  cannot  be  over  estimated.  I  respectfully  recommend  that  a  small 
annual  appropriation  be  made  for  its  benefit. 

"  An  army  medical  school,  in  which  medical  cadets  and  others  seeking  admis- 
sion into  the  corps,  could  recieve  such  special  instruction  as  would  better  fit 
them  for  commissions,  and  which  they  cannot  obtain  in  the  ordinary  medical 
schools,  is  a  great  desideratum.  Such  an  institution  could  be  established  in 
connection  with  any  general  hospital,  with  but  little  if  any  expense  to  the 
United  States.  A  hospital  of  a  more  permanent  character  than  any  now  in 
this  city  is,  I  think,  necessary,  and  will  be  required  for  years  after  the  present 
rebellion  has  ceased.  I  therefore  recommend  that  suitable  buildings  be  pur- 
chased or  erected  for  that  purpose.  If  this  is  done,  the  medical  school  and 
museum  will  be  important  accessions  to  it. 

"  Experience  has  shown  that  a  most  useful  class  of  officers  was  authorized 
by  the  act  relative  to  the  medical  storekeepers.  The  number  now  authorized 
is  too  small.  They  could  very  properly  perform  the  duties  of  medical  purveyors, 
now  performed  by  medical  officers,  and  thus  officers  who  have  been  educated 
with  special  reference  to  service  as  physicians  and  surgeons,  and  who  are  now 
acting  as  medical  purveyors,  would  be  enabled  to  resume  their  proper  duties. 
I  therefore  recommend  an  addition  to  the  medical  storekeepers. 

"  At  present  the  washing  of  clothes  in  general  hospitals  is  provided  for  as 
follows :  One  matron  is  provided  for  every  twenty  patients,  who  receives  a  com- 


534 


American  Intelligence. 


[April 


pensation  of  six  dollars  per  month  and  one  ration.  Great  difficulty  is  experi- 
enced in  large  general  hospitals  in  procuring  a  sufficient  number  of  matrons  to 
perform  this  duty,  and  I  have  the  honor  to  propose  that,  instead  of  this  now 
unreliable  plan,  a  sum  of  money  equivalent  to  the  pay  and  allowance  of  a  matron, 
say  twelve  dollars  for  every  twenty  patients,  be  monthly  allowed  to  every  gene- 
ral hospital,  to  be  appropriated  for  laundry  purposes  at  the  discretion  of  the 
surgeon  in  charge,  whether  to  the  payment  of  matrons  or  the  payment  of  bills 
for  washing  by  steam  or  otherwise. 

"  The  10th  section  of  the  act  approved  July  17, 1862,  gives  additional  rank  to 
officers  of  the  Adjutant-Generals,  Quartermasters,  Subsistence,  and  Inspector 
Generals  Department  who  are  serving  on  the  staff  of  Commanders  of  Army 
Corps.  There  is,  I  think,  manifest  propriety  in  extending  the  provisions  of  this 
act  to  the  officers  of  the  medical  department  who  may  be  on  duty  with  such 
command  as  medical  directors,  and  I  respectfully  ask  for  such  extension. 

"  The  Engineer  and  Ordnance  Departments  are  charged  with  the  erection  of 
buildings  which  requires  special  knowledge.  The  building  of  hospitals  also 
requires  knowledge  of  a  peculiar  character,  which  is  not  ordinarily  possessed  by 
officers  out  of  the  medical  department.  It  would,  therefore,  appear  obviously 
proper  that  the  medical  department  should  be  charged  with  the  duty  of  building 
the  hospitals  which  it  is  their  duty  to  administer. 

"  In  the  matter  of  transportation  the  interests  of  the  service  require  that  the 
medical  department  should  be  independent.  Much  suffering  has  been  caused  by 
the  impossibility  of  furnishing  supplies  to  the  wounded,  when  those  supplies 
were  within  a  few  miles  of  them  in  great  abundance. 

"  The  establishment  of  a  laboratory,  from  which  the  medical  department  could 
draw  its  supplies  of  chemical  and  pharmaceutical  preparations,  similar  to  that 
now  so* successfully  carried  on  by  the  medical  department  of  the  Navy,  would 
be  a  measure  of  great  utility  and  economy.  I  therefore  respectfully  recommend 
that  authority  be  given  for  this  purpose. 

"In  regard  to  the  age  at  which  recruits  are  received  into  service  a  change  is 
imperatively  demanded,  both  for  the  interests  of  the  army  and  the  welfare  of 
individuals.  The  minimum  is  now  fixed  at  eighteen  years,  and  it  is  not  uncom- 
mon to  find  soldiers  of  sixteen  years  old.  Youths  of  these  ages  are  not  deve- 
veloped,  and  are  not  fit  to  endure  the  fatigues  and  privations  of  military  life. 
They  soon  break  down,  become  sick,  and  are  thrown  upon  the  hospitals.  As  a 
measure  of  economy  I  recommend  that  the  service  age  of  recruits  be  fixed  by 
law  at  twenty  years. 

"The  present  manner  of  supporting  the  cartridge-box  is  productive  of  hernia 
or  rupture.  Many  instances  in  support  of  this  statement  have  occurred  since 
the  commencement  of  the  rebellion,  and  reports  on  the  subject  are  frequently 
received  from  medical  officers.  I  recommend  that,  instead  of  being  carried  by 
a  belt  around  the  waist,  the  cartridge-box  be  supported  by  a  shoulder-strap. 
This  would  entirely  obviate  the  evil. 

"At  the  last  session  of  Congress  the  sum  of  two  millions  of  dollars  was  appro- 
priated for  the  relief  of  discharged  soldiers.  I  recommend  that  one  million  of 
dollars  of  this  sum  be  set  aside  for  the  establishment  of  a  permanent  home  for 
those  who  have  been  disabled  in  their  country's  service.  This  measure  is  one 
of  such  importance  that  I  forbear  entering  into  details  at  this  early  period.  An 
establishment  of  the  kind,  organized  upon  an  approved  plan,  would  be  produc- 
tive of  incalculable  benefit. 

"  Soon  after  my  appointment  I  issued  circulars  to  medical  officers,  inviting 
them  to  co-operate  in  furnishing  materials  for  a  Medical  and  Surgical  History 
of  the  Rebellion.  A  large  number  of  memoirs  and  reports  of  great  interest  to 
medical  science,  and  military  surgery  especially,  have  been  collected,  and  are 
now  being  systematically  arranged.  The  greatest  interest  is  felt  in  this  labour 
by  the  medical  officers  of  the  army  and  physicians  at  large. 

"The  reorganization  of  the  medical  department  necessitated  a  new  set  of 
regulations  for  its  guidance.  Under  your  orders  a  board  has  been  in  session 
preparing  a  new  code.  Their  labours  have  been  very  much  interfered  with  by 
the  necessity  of  detailing  them,  from  time  to  time,  for  more  imperative  duties, 


1863.] 


Domestic  Summary. 


535 


but  I  expect  to  be  able  to  submit  to  you,  in  a  short  time,  a  complete  set  of  regu- 
lations for  your  approval. 

"I  have  deemed  it  my  duty,  with  your  sanction,  to  visit,  from  time  to  time, 
the  hospitals  and  armies  of  the  eastern  portion  of  the  country.  I  have  thus  been 
enabled  to  make  myself  acquainted  with  their  sanitary  condition  and  medical 
wants.    I  hope,  ere  long,  to  be  able  to  extend  these  inspections  to  the  west. 

"  A  uniform  diet  table  for  general  hospitals  has  been  prepared  with  great 
care,  and  promises  to  work  advantageously." 


OBITUARY  NOTICES. 

Died,  in  Louisville,  Ky.,  on  the  7th  March,  1863,  of  broncho-pneumonia,  com- 
plicated with  gastric  and  renal  derangement,  and  attended  with  fever  of  the 
typhoid  type,  Charles  W.  Short,  M.  D.,  late  Prof,  of  Materia  Medica  in  the 
University  of  Louisville. 

Dr.  Short  was  born  in  Greenfield,  "Woodford  County,  Kentucky,  October  6, 
1794,  and  was,  therefore,  in  the  sixty-ninth  year  of  his  age  at  the  period  of  his 
death. 

Such  a  man  ought  not  to  be  allowed  to  pass  from  this  stage  of  action  without 
some  attempt  to  appreciate  the  part  he  performed  in  the  drama  of  life.  Occupy- 
ing, for  so  many  years,  the  honourable  and  useful  position  of  a  public  teacher  in 
the  medical  profession,  he  necessarily  formed  a  large  circle  of  friends,  now  scat- 
tered over  a  wide  expanse  of  country,  whose  hearts  will  be  saddened  by  the 
intelligence  that  his  pure  and  peaceable  spirit  has  winged  its  flight  to  another 
sphere. 

Dr.  Short  took  his  degree  of  Doctor  of  Medicine  in  the  University  of  Penn- 
sylvania about  the  year  1815,  and  began  the  practice  of  his  profession  in  Lexing- 
ton, Kentucky,  not  far  from  the  place  of  his  birth.  He  was,  however,  soon 
induced  to  remove  to  the  Green  River  section  of  the  State,  and  settled  in  Hop- 
kinsville,  Christian  County,  where  he  was,  we  believe,  as  successful  as  a  man  of 
his  great  modesty  and  retiring  habits  could  have  expected.  About  the  year 
1825  or  1826,  he  was  appointed  to  the  Chair  of  Materia  Medica  and  Medical 
Botany  in  Transylvania  University  at  Lexington,  Kentucky,  which  opened  up 
to  him  a  path  suited  to  his  scientific  and  literary  taste.  The  medical  school  of 
Lexington  was,  at  that  time,  in  the  zenith  of  its  renown,  and  its  halls  resounded 
with  the  polished  elocution  of  Dr.  Charles  Caldwell,  and  the  fervid  declamation 
of  Dr.  Daniel  Drake,  while  Dr.  Benjamin  Winslow  Dudley,  also  a  member  of  the 
faculty,  was  the  oracle  of  Western  Surgery. 

With  such  colleagues  as  these  Dr.  Short  quietly  and  unostentatiously  took 
his  stand,  and,  relinquishing  the  practice  of  medicine,  for  which  he  had  an  anti- 
pathy, applied  himself  with  industry  and  zeal  to  the  study  which  was  ever  after- 
wards the  business  and  the  pleasure  of  his  life,  namely,  botany,  which  he  enriched 
by  frequent  and  lengthy  excursions  in  search  of  our  indigenous  plants.  He  was 
at  this  time  one  of  the  editors  of  the  Transylvania  Medical  Journal,  to  which 
he  contributed  many  valuable  papers,  embodying  the  results  of  his  scientific 
explorations. 

After  the  disruption  of  the  Transylvania  Medical  School,  Dr.  Short  accepted 
his  favourite  chair,  for  which  he  was  so  pre-eminently  qualified,  in  the  Univer- 
sity of  Louisville,  and  removed  to  that  city  in  1838,  one  year  after  the  organiza- 
tion of  its  medical  school.  Here  he  was  again  associated  with  Drs.  Caldwell 
and  Drake  and  other  able  collaborators,  under  whom  the  school  rapidly  rose  to 
distinction,  and  attracted  larger  classes  than  had  ever  before  been  assembled  in 
the  Mississippi  Yalley. 

Dr.  Short's  connection  with  the  Louisville  school  continued  until  1849,  when 
he  resigned  his  professorship  and  retired  to  Hayfield,  an  elegant  and  tasteful 
villa  five  miles  from  the  city.  Previous  to  his  retirement  he  had,  by  inheritance 
and  his  own  industry,  become  possessed  of  a  fortune,  which  enabled  him  to  enjoy 
his  otium  cum  dignitate,  and  to  furnish,  at  the  same  time,  a  suitable  outfit  to 
his  children  as  they  left  the  paternal  mansion,  besides  responding  to  the  calls  of 
benevolence,  both  public  and  private. 


536 


American  Intelligent 


[April  1863.] 


No  small  share  of  Dr.  Short's  time,  after  his  retirement  to  private  life,  was 
devoted  to  the  preservation  of  the  dried  specimens  of  plants  and  flowers,  of 
which  he  had  gathered  a  large  and  valuable  collection.  This  was  to  him  a  labour 
of  love,  and  these  mute  objects  of  his  tender  care,  embalmed  and  classified  in 
the  herbariums  which  he  has  left  behind  him,  long  may  they  be  preserved  to 
testify  to  his  patience  and  gentleness,  and  skill. 

As  a  lecturer,  Dr.  Short's  style  was  chaste,  concise,  and  classical,  and  his 
manner  always  grave  and  dignified.  His  lectures  were  always  carefully  and  fully 
written,  and  read  in  the  lecture-room  with  a  good  voice  and  correct  emphasis. 
He  never  made  the  least  attempt  at  display,  nor  set  a  clap-trap  in  all  his  life. 

As  a  man,  Dr.  Short  was  remarkable  for  his,  we  had  almost  said,  fastidious 
modesty,  diffidence,  and  retiring  disposition.  This  last  trait  was  so  strongly 
marked  that  a  stranger  might  have  deemed  him  to  be  an  ascetic  ;  but  never  did 
a  kinder  heart  beat  in  human  bosom.  His  heart  was  indeed  always  in  the  right 
place,  and  alive  to  the  noblest  and  most  generous  impulses.  As  to  his  probity, 
it  was  as  nearly  perfect  as  is  possible  to  fallen  humanity.  There  was  never  a 
stain  upon  his  honour,  and  the  breath  of  calumny  never  tarnished  his  name. 

H.  M. 

Died,  in  Hartford,  Connecticut,  on  the  19th  of  March,  aged  sixty-four  years, 
Charles  Hooker,  M.  D.,  Prof,  of  Anatomy  and  Physiology  in  Medical  Institu- 
tion of  Yale  College. 

In  the  death  of  this  eminent  physician  the  public  of  Hartford  have  met  with 
a  great  loss.  So  long  had  he  moved  about  among  them  as  a  physician — a  period 
of  forty  years — and  so  active  and  energetic  has  he  been  during  all  this  time  in 
performing  the  duties  of  his  profession,  standing  forth  as  one  of  the  prominent 
men  of  this  community,  that  the  ties  which  have  bound  him  to  this  whole  people, 
in  all  its  grades  and  classes,  are  numerous  and  strong,  and  now  that  these  ties 
are  suddenly  sundered,  it  is  no  wonder  that  the  expressions  which  are  upon  every 
one's  tongue  are — How  many  will  miss  him  !  How  great  a  loss !  The  events 
of  a  physician's  life  are  few,  and  yet  if  he  be  skilful,  diligent,  and  faithful,  there 
is  a  rich  unwritten  history  left  in  the  hearts  of  those  to  whom  he  has  been  both 
the  friend  and  physician  in  the  hours  of  suffering  and  bereavement.  So  it  was 
with  our  friend.  A  few  lines  will  suffice  to  give  the  main  events  of  his  history. 
He  was  born  in  Berlin,  in  this  State,  a  descendant  of  that  eminent  and  gifted 
man  who  was  the  leader  of  the  first  settlers  of  Hartford,  the  Rev.  Thomas  Hooker. 
He  graduated  with  honour  in  Yale  College  in  1820,  in  the  class  of  which  Pres. 
"Woolsey  and  Dr.  Bacon  were  members.  On  graduating,  as  he  afterwards  did, 
from  the  medical  institution  of  the  college,  he  began  practice  in  this  city,  and 
from  that  time  to  this  he  has  been  known  as  one  of  the  busiest  and  most  inde- 
fatigable men  in  this  community.  In  1838  he  was  appointed  to  the  chair  of 
anatomy  and  physiology,  and  the  numerous  graduates  of  the  medical  school  can 
testify  to  his  great  skill  and  energy  as  a  teacher. 

The  character  of  Dr.  Hooker  is  not  a  common  one.  An  independent  thinker, 
his  energy  prompted  him  to  press  his  views  upon  the  minds  of  others,  and  he 
therefore  made  a  decided  impression  upon  the  principles  and  practice  of  his 
brethren  in  the  profession.  No  man  ever  showed  more  earnestness  and  assiduity 
in  his  calling,  and  these  were  just  as  manifest  in  his  last  days,  when  most  men 
incline  to  some  relaxation  of  their  labours,  as  they  were  when  the  ardour  of  his 
youth  was  upon  him.  Indeed  this  ardour  never  left  him,  and  he  never  discovered 
that  old  age  was  coming  upon  him.  Faithful  and  energetic  to  the  last,  he  ex- 
posed himself  freely  to  cold  and  fatigue,  in  behalf  of  some  patients  in  whom  he 
felt  a  deep  interest,  even  after  his  sickness  had  fairly  begun,  and  so  he  may  be 
said  to  have  died  in  the  very  midst  of  his  labours.  What  we  deem  to  be  the 
grand  fact  of  his  professional  life,  standing  out  prominent  before  all  others,  and 
written  in  deep  lines  upbn  the  hearts  of  multitudes  in  this  community,  is,  that 
he  performed  his  labours  for  the  sick  irrespective  of  reward,  for  he  was  just  as 
ready  to  obey  the  calls  of  the  poor  as  those  of  the  rich.  The  genial  and  ardent 
social  qualities  of  Dr.  Hooker  added  much  to  his  influence,  and  therefore  his 
usefulness,  as  a  physician.  W.  H. 


INDEX. 


A. 

Abscesses,  iodine  injections  in,  221 
Air-cells,  epithelium  of,  183 
Air-passages,  removal  of  foreign  bodies  from, 
56 

Albuminate  of  iron  and  soda  as  a  therapeu- 
tic agent,  462 

Alcohol,  is  it  food  ?  467 

Alkaline  lactates  and  pepsin  in  indigestion, 
495 

Almond  food  as  a  substitute  for  bread  in 

diabetes,  138 
Amnion,  unusual  density  of,  517 
Amputations  after  battle  of  Antietam,  44 
Anaesthesia  caused  by  diseases  of  the  lungs, 

201 

Anaesthetics,  local,  186 

Anderson,  eczema  of  external  auditory  mea- 
tus, 214  * 

Aneurism,  popliteal,  216 

Angina  pectoris  caused  by  tobacco,  205 

Anstie,  poisoning  by  morphia,  caffeine  as  an 
antidote,  520 

Antidote  to  strychnia,  258 

Antimonii  et  potass,  tart,  cum  ol.  tiglii  in 
varicose  veins,  382 

Antiperiodics,  new,  463 

Antiscorbutic,  vinegar  as,  267 

Apnoea  neonatorum,  256 

Apoplexy,  influence  of  hypertrophy  of  heart 
and  diseases  of  cerebral  arteries  on,  479 

Aran,  action  and  uses  of  codeia,  184 

Areca  nut,  taenia  treated  with,  496 

Arnold,  can  pregnancy  follow  rape,  272 

Arsenite  of  caffeine  and  tanno-arsenic  acid  as 
antiperiodics,  463 

Artificial  delivery  in  extremis,  245 

Ashhurst,  surgical  cases,  342 

Asthma,  review  of  Salter  on,  97 

Atrophy,  progressive  muscular,  136 

Atropia,  internal  administration  of,  464 

Aveling,  vaginal  lithotomy,  511 


B. 

Bader,  tumours  at  base  of  brain,  127 
Balfour,  cause  of  death  under  chloroform, 
257 

Ball,  new  methods  of  detecting  the  presence 
of,  in  wounds,  499 

Barracks  and  hospitals,  review  of  report  of 
commission  for  improving  sanitary  condi- 
tion of,  112 

Beatty,  inversion  of  urinary  bladder,  213 

Beau,  tobacco  as  a  cause  of  angina  pectoris, 
205 

Bedford's  obstetrics,  notice  of,  430 


Beer  in  therapeutics,  185 
Belladonna,  poisoning  by,  521 
Bell,  rheumatic  endocarditis  and  pericardi- 
tis, 207 

Belluzi,  artificial  delivery  in  extremis,  245 
Bennett,  ligation  of  subclavian  artery,  266 
Bethune,  double  vision,  528 
Bibliographical  notices — 
 Addresses  before  British  Medical  As 

sociation,  169 

 Bedford's  Obstetrics,  430 

 Bourchardat's  Annuaire  for  1862, 

443 

 Bulletin  of  the  New  York  Academy 

of  Medicine,  423 
 Gay,  Primary  Treatment  of  Wounds, 

182 

 Habershon  on  Diseases  of  Abdomen, 

174 

 Holmes,  Border  Lines  of  Knowledge, 

157 

 Insane  Asylum  Reports  of  British 

American  Provinces,  432 

 Jacobi,  Dentition  and  its  Derange- 
ments, 163 

 Jarvis,  Sanitary  Condition  of  U.  S. 

Army,  161 

 Lizars,  Use  and  Abuse  of  Tobacco, 

457 

 Meigs'  Obstetrics,  421 

■  Paine's  Institutes  of  Medicine,  181 

 Power,  Anatomy  of  Arteries,  178  ' 

 Registration  Reports  of  Vermont, 

424 

 Reports  of  American  Institutions  for 

the  Insane,  148 

 Storer's  Dictionary  of  the  Solubility 

of  Chemical  Substances,  430 

 Transactions  of  State  Medical  Socie- 
ties, 139 

 Wilson  on  Diseases  of  the  Skin,  441 

 Woodward's  Hospital  Steward's  Ma- 
nual, 182 

Bilifulvin  and  haematoidin,  identity  of,  184 
Bill,  new  method  of  performing  tracheotomy, 
63 

Birkett,  arrest  of  development  of  humerus, 
136 

Births,  repeated  twin,  251 

Bladder,  how  to  relieve  pain  in  diseased,  223 

Blake,  primary  pyaemia,  67 

Blood  stains,  detection  of,  258 

Bloomingdale  Asylum  for  Insane,  notice  of 
report,  153 

Body  weight,  changes  of,  in  women,  254 

Boils  and  carbuncles,  subcutaneous  treat- 
ment of,  222 


538 


Index. 


Bones,  urine  in  diseases  of,  508 
Bouchardat,  diseases  produced  by  bad  pota- 
ble water.  475 
Bouchardat's  Annuaire,  notice  of,  443 
Boucbut,  ansesthesia  produced  by  diseases  of 

lungs,  201 
Bowditch,  paracentesis  thoracis,  17 
Brandt,  extra-uterine  pregnancy,  251 
Brewster,  characteristics  of  the  age,  524 
British  American  Provinces,  notice  of  Insane 

Hospital  reports,  432 
Brittain,  repeated  twin  births,  251 
Bromine,  formula  for  solution  of,  385 
Bronchus,  tracheotomy  tube  in,  220 
Bronzed  skin  cured,  208 
Browne,  ligation  of  subclavian,  70 
Bruce,  retroversion  of  pregnant  uterus,  253 
Bryant,  arrest  of  development  of  humerus, 
137 

Bryant,  diseases  of  urinary  organs,  131 
Buchanan,  white  fibro-serous  discharge  from 
thigh,  491 

Bullen,  iodine  injections  in  ovarian  dropsy, 
239 

Burggraeve,  fermentative  treatment  of-  dis- 
ease, 471 
Burrows'  address,  notice  of,  169 


C. 

Csesarean  section  after  rupture  of  uterus,  272 
Caffeine  as  an  antidote  to  morphia,  520 
Calculus,  black,  from  kidney,  270 
Campbell  de  Morgan,  popliteal  aneurism, 
216 

Carbazotate  of  iron,  188 

Carbuncles,  subcutaneous  treatment  of,  222 

Carcinoma,  abdominal,  263 

Carothers,  compound  comminuted  fractures 

of  femur  from  minie  balls,  350 
Cataract,  inferior  section  of  cornea  for,  240 
Catheterism  of  Eustachian  tube,  dangers  of, 

224 

Cerebellum,  physiology  and  pathology  of, 

459 

Cerebral  hemorrhage,  478 
Chambers,  renewal  of  life,  review  of,  387 
Characteristics  of  the  age,  524 
Chestnut  leaves  in  pertussis,  528 
Chipperfield,  metallic  sutures,  226 
Chloroform,  cause  of  death  under,  257 
Cholesterine  and  seroline  as  secretions,  289 
Churchill  on  Hodge's  pessary,  254 
Citrate  of  quinia  and  iron  with  strychnia, 
466 

  of  iron  and  strychnia,  466 

  of  iron  and  zinc,  466 

Close,  chestnut  leaves  in  pertussis,  528 

Clo3madeuc,  blow  on  head  followed  by  death 
two  years  subsequently,  219 

Clubbed  fingers  in  diseases  of  the  chest,  487 

Codeia,  action  and  uses  of,  184 

Coffee,  iodized,  190 

Colloid  cancer,  84 

Conjunctivitis,  opium  in,  243 

Connecticut  Medical  Society,  notice  of  pro- 
ceedings of,  145 

Conservative  medicine  applied  to  therapeu- 
tics, 22 

Consumption,  review  of  Smith  on,  91 
 ,  therapeutics  of,  201 


Cooper,  ophthalmic  ointments,  243 

 ,  opium  in  conjunctivitis,  243 

Cornea,  inferior  section  of,  for  cataract,  240 
Corrosive  sublimate,  antidote  to,  336 
Corse,  intra-uterine  hydrocephalus,  81 
Cosmao-Dumenez,  iodine  injections  in  ab- 
scesses, 221 
Cotton,  action  of  sesquichloride  of  iron  on, 
494 

 ,  therapeutics  of  consumption,  201 

Croup,  tracheotomy,  269 

Czermak  on  laryngoscope,  notice  of,  121 


D. 

Danilewsky,  pancreatic  juice,  460 
Davies,  injury  of  neck,  79 

 ,  silver  wire  ligatures,  373 

Davy,  local  anesthetics,  186 
Deafness  consequent  on  rheumatism,  223 
Delirium  tremens,  treatment  of,  198 
Delioux,  deafness  consequent  on  rheuma- 
tism, 223 

Dentition  and  its  derangements,  163 
De  Ricci,  phloridzine,  188 
Diabetes,  almond  food  in,  138 

 ,  causes,  &c,  of,  494 

 mellitus,  effects  of  diet  and  drugs 

on,  492 

 mellitus  ending  in  phthisis,  209 

Diabetic  urine,  means  of  distinguishing,  210 
Dialysis  applied  to  detection  of  poisons,  520 
Dickinson,  rupture  of  heart  from  violence, 
521 

Digitalis,  action  of,  463 

Dislocation  reduced  by  manipulation,  75 

Dix,  wire  compress  as  a  substitute  for  the 

ligature,  500 
Dolbeau,  symptom  of  fracture  of  base  of 

skull,  504 
Dowell,  trismus  nascentium,  51 
Draper,  carbazotate  of  iron,  188 
 ,  citrate  of  quinia  and  iron  with 

strychnia,  466 

 ,  syrup  of  carbonate  of  iron,  190 

Dropsy  of  ovum,  515 

E. 

Eberth,  epithelium  of  air-cells,  183 
Eczema  of  external  auditory  meatus,  214 
Electricity,  action  of,  in  metamorphosis  of 

organic  substances,  460 
Electro-galvanism,  191 
Embolism,  479 

Emphysema,  generalized,  488 

Engel,  direction  taken  by  hernial  sac  when 

reduced,  226 
 ,  double  inguinal  hernia  of  same  side, 

226 

Ensiform  cartilage,  dislocation  of,  518 
Epidemic  diseases  in  Great  Britain  in  1861 

and  1862,  522 
Epithelium  of  air-cells,  183 
Erdmann,  detection  of  blood  stains,  258 
Ether  in  deafness,  223 

Eustachian  tube,  dangers  of  catheterism  of, 
224 

Extra-uterine  foetation,  130 

 pregnancy,  251,  252 

 ,  foetus  in  hernial 

sac,  252 


♦ 


Index. 


539 


F. 

Fabri,  albuminate  of  iron  and  soda,  362 

 ,  reunion  of  intra-capsular  fractures  of 

femur,  219 

Fallopian  tube  and  ovary,  organic  connec- 
tion, 255 

Fascial  nerve,  deep  origin  of,  183 

Favre's  method  of  detecting  metallic  bodies 
in  wounds,  499 

Femur,  compound  comminuted  fractures  of, 
from  minie  balls,  350 

 ,  fracture  of,  218 

 ,  reunion  of  intra-capsular  fractures 

of,  219 

Fergusson  on  wire  compress  as  substitute  for 

ligature,  502 
Fermentation,  diseases  depending  on,  467 
Fermentative  theory  of  disease,  471 
Fibula,  luxation  of  head  of,  385 
Fisher,  amputations  after  battle  of  Antietam, 

44 

Flemming,  internal  exhibition  of  atropia  and 
strychnia,  464 

Flint,  conservative  medicine  applied  to  the- 
rapeutics, 22 

 ,  hydro-peritoneum, 306 

Food  impacted  in  larynx,  220 

Forceps  in  tedious  labour,  246 

Foreign  bodies  in  air-passages,  56 

Fracture  of  base  of  skull,  symptoms  of,  504 

Fraser,  statistics  of  labour,  363 

Fremy,  malt  and  beer,  185 

French,  subcutaneous  treatment  of  boils  and 
carbuncles,  222 

Friedberg,  imperforate  anus,  511 

Friends'  Asylum  for  Insane,  notice  of  report' 
of,  151 

Fuller,  action  of  digitalis,  463 
G. 

Gairdner's  clinical  medicine,  review  of,  403 

Galvanic  electricity,  191 

Garibaldi's  wound,  218 

Gassner,  changes  in  body  weight  in  women, 

254 

Gastinel,  arsenite  of  caffeine  and  tanno-arse- 

nic  acid,  463 
Gay,  primary  treatment  of  wounds,  182 
Gilbert,  stone  in  bladder,  85 
Gold  dust  and  iron  filings  as  an  antidote  to 

corrosive  sublimate,  339 
Gosselin,  supra-pelvic  hematocele,  519 
Gouraud,  embolism,  479 
Great  Britain,  epidemic  disease  in  1861  and 

1862,  522 
Greaves,  apnoea  neonatorum,  256 
Grimsdale,  placentae  of  triplets,  519 
Gull,  progressive  muscular  atrophy,  136 
Gunshot  wound  of  chest  and  abdomen,  380 
Guy's  Hospital  Reports,  review  of,  125 

H. 

Habershon,  diseases  of  abdomen,  notice  of, 
174 

 ,  disease  of  heart,  130 

 ,  on  podophyllin,  130 

Haematoidin  and  bilifulvin,  identity  of,  184 
Halifax,  N.  S.,  notice  of  report  of  Lunatic 

Asylum  near,  440 
Hamilton,  forceps  in  tedious  labour,  246 
 ,  new  transfusion  apparatus,  248 


Hamilton,  post  partum  hemorrhage,  248 
Haemine  crystals  in  different  animals,  259 
Harley,  physiology  and  pathology  of  supra- 
renal capsules,  207 
Hart,  inferior  section  of  cornea  for  cataract, 
240 

Harvey,  detection  of  poisons  by  dialysis,  520 

Haughton,  nicotia  in  tetanus  and  poisoning 
by  strychnia,  220 

Head,  blow  on,  sudden  death  two  years  sub- 
sequently, 219 

Heart,  disease  of,  130 

 rupture  of,  from  violence,  521 

Heller,  urine  in  hydrophobia,  492 

Hemorrhage,  post-partum,  248 

Hernial  sac,  direction  taken  when  reduced, 
226 

Hicks,  extra-uterine  foetation,  130 

 ,  uterine  polypi,  131 

Hiffelsheim,  permanent  voltaic  current,  190 
Hip-joint,  amputation  at,  for  malignant  dis- 
ease, 507 

Hjaltelin,  typhus  in  Iceland,  194,  196 
Hodge's  pessary  for  retroversion  of  uterus, 
254 

Holmead,  rupture  of  uterus,  Caasarean  sec- 
tion, 272 

Holmes'  introductory  lecture,  notice  of,  157 

 Surgery,  review  of,  408 

Hooker,  obituary  notice  of  Charles,  536 
Horse-hair  as  a  substitute  for  wire  for  su- 
tures, 227 

House-maid's  knee,  iodine  injections  in,  222 
Hoyland,  recovery  after  transfixion  of  thorax 

by  iron  bar,  504 
Hunt,  tetanus  and  paralysis  coexistent,  82 
Huseman,  epidemic  produced  by  eating  dis- 
eased meat,  477 
Hydrocephalus,  intra-uterine,  81 
Hydroperitoneum,  clinical  report  on,  306 
Hydrophobia,  urine  in,  492 
Hypodermic  injections  in  neuralgia,  87 

I. 

Iceland,  typhus  in,  194 

Imperforate  anus,  511 

Inguinal  hernia,  double,  of  same  side,  226 

Inman,  is  alcohol  food?  467 

Insane  Asylum  reports,  notices  of,  148,  432 

Iodine  injections  in  acute  abscesses,  221 

 in  ovarian  dropsy,  239 

 in  swelled  bursae  patellee, 

222 

Iodized  coffee,  196 

Ireland,  action  of  ozonized  air  on  animals, 

462 

Iron,  action  of,  on  tissue  change,  461 

 ,  new  preparations  of,  188,  190,  466 

Irvine,  ovarian  cyst  discharging  through 
vagina,  255 

J. 

Jacobi,  dentition  and  its  derangements,  no- 
tice of,  163 

 ,  tracheotomy  in  croup,  269 

Jaffe,  identity  of  haamatoidin  and  bilifulvin, 
184 

Jarvis,  sanitary  condition  of  IT.  S.  Army, 

notice  of,  161 
Johnston,  gold  dust  and  iron  filings  as  an 

antidote  to  corrosive  sublimate,  336 


540 


Index. 


Jolly  and  Musset,  spontaneous  generation, 
659 

Jones,  cerebral  hemorrhage,  478 
K. 

Kennedy,  typhus  and  typhoid  fevers  in  Dub- 
lin, 192 

,  measles  from  flaxseed  meal,  474 

 ,  treatment  of  typhoid  fever,  193 

Kidd,  ovariotomy  in  Ireland,  239 

pessary  retained  thirteen  years,  519 
Kidney,  black  calculus  from,  270 
Kirkvrood,  iodine  injections  in  swollen  bursa 

patella,  222 
Knox,  cysts  in  urinary  bladder,  211 
Kurzak,  tannin  as  antidote  of  strychnia,  258 

L. 

Labour,  cause  of  delay  in,  246 

 ,  forceps  in  tedious,  246 

 ,  statistics  of,  363 

Lancereau,  embolism,  479 

Larynx,  food  impacted  in,  220 

Laycock,  treatment  of  delirium  tremens,  198 

Leasure,  abdominal  carcinoma,  263 

Lee,  ovariotomy,  232 

Leven  and  Ollivier  on  cerebellum,  459 

Levick,  colloid  cancer,  84 

,  protracted  hypodermic  injections,  87 
Lizars  on  use  and  abuse  of  tobacco,  notice 
of,  457 

Longview  Asylum  for  Insane,  notice  of  re- 
port of,  155 
Lorinser,  urine  in  diseases  of  bones,  508 
Lyell,  fermentative  treatment  of  disease,  471 

M. 

Malt  and  beer  in  therapeutics,  185 
Mapother,  osteo-aneurism,  505 
Massachusetts  Medical  Society,  notice  of, 

communications  of,  139 
.  State  Lunatic  Hospital,  notice 

of  report  of.  153 
McBride,  vinegar  as  an  antiscorbutic,  267 
McClintock,  diseased  placenta,  256 

—  ,  dropsy  of  ovum,  515 

McLean  Asylum  for  Insane,  notice  of  report 

of,  153 

Measles  from  an  unusual  cause,  474 
Meat,  epidemic  produced  by  eating  diseased, 
477 

Medico-Chirurgical  Transactions,  review  of, 
394 

Meigs'  Obstetrics,  notice  of,  421 

Melchiori,  induration  of  sterno-cleido-mas- 

toid  muscle  in  infants,  519 
Metallic  sutures,  226,  ib. 
Minie  balls,  compound  comminuted  fractures 

of  femur  from,  350 
Morbus  Addisonii,  208 
Moxon,  enlargement  of  nerves,  137 
Mucous  membrane  of  tongue  and  mouth, 

abnormal  condition  of,  215 
Muller,  diabetes,  494 

 ,  extra-uterine  foetation,  foetus  in  her- 
nial sac,  252 

N. 

Neck,  injury  of,  79 
Necrosis,  232 

Nelaton,  fibrous  tumours  of  iliac  fossa,  231 


Nelaton,  Garibaldi's  wound,  218 

Nelaton's  probe  for  detecting  metallic  bodies 
in  wounds,  499 

Neligan,  abnormal  condition  of  mucous  mem- 
brane of  tongue  and  mouth,  215 

Nerves,  enlargement  of,  137 

New  Brunswick,  notice  of  report  of  Lunatic 
Asylum  at,  438 

New  Hampshire  Asylum  for  Insane,  notice 
of  report  of,  156 

New  York  Academy  of  Medicine,  notice  of 
bulletin  of,  423 

Nicotia  in  tetanus  and  poisoning  by  strych- 
nia, 220,  496 

Nunn,  enormous  spleen,  489 

O. 

Oakum  as  a  substitute  for  lint,  268 
Obituary  notices,  535,  536 
Ointments,  ophthalmic,  243 
Oilier,  metallic  sutures,  226 
Opium  in  conjunctivitis,  243 
Ord,  death  during  convalescence  from  ty- 
phoid fever  from  over-eating,  266 
Osteo-aneurism,  505 

Ovarian  cyst  discharging  through  vagina,  255 
■  dropsy  cured  by  iodine  injections, 

239,  376 
Ovariotomy,  232,  239,  355,  511 
Ovum,  dropsy  of,  515 

Owen,  premature  delivery,  rare  presentation, 
77 

Oxytoxic,  tartrate  of  antimony  as,  513 
Ozonized  air,  influence  of,  on  animals,  462 

P. 

Paget's  Address,  notice  of,  172 
Paillon,  means  of  distinguishing  diabetic 
urine,  210 

Paine's  Institutes  of  Medicine,  notice  of,  181 
Painless  parturition,  244 
Pakrowsky,  action  of  iron  on  tissue  change, 
461 

Panck,  organic  connection  of  Fallopian  tube 

with  ovary,  255 
Pancreatic  juice,  principles  of,  460 
Paracentesis  thoracis,  17 
Parker,  tartrate  of  antimony  as  an  oxytoxic, 

513 

Parturition,  painless,  244 
Peaslee,  double  ovariotomy,  355 
Pennsylvania  Hospital  for  Insane,  notice  of 

report  of,  148 
Pessary  retained  thirteen  years,  519 
Petrequin,  alkaline  lactates  and  pepsin  in 

indigestion,  495 
Petroff,  carbonate  of  ammonia  in  blood  in 

in  ursemic  poisoning,  210 
Phloridzine,  188 

Phthisical  persons,  conditions  affecting  con- 
stitution of,  482 

Phthisis,  action  of  sesquichloride  of  iron  on, 
494 

 ,  cases  of  arrest  of,  485 

Pile,  dislocation  of  shoulder  reduced  by 

manipulation,  75 
Placenta,  diseased,  250 

 of  triplets,  519 

 prsevia,  78  ' 

Pleuritic  effusions  in  relation  to  thoracente- 
sis, 202 


Index. 


541 


Podophyllin  as  a  purgative,  130 
Poisoning  by  belladonna,  521 

 bitter  almonds  with  iodide  of 

iron,  261 

.  ■  morphia,  520,  ibid. 

 i  pollen  of  tiger  lily,  271 

 •  strychnia,  morphia,  chloro- 
form, Ac,  259 
Poisons,  detection  of,  by  dialysis,  520 
Pollen  of  tiger  lily,  poisoning  by,  271 
Polli,  diseases  depending  on  morbific  fer- 
mentation, 467 
Popliteal  aneurism,  rapid  spontaneous  cure 
of,  216 

Potter,  operation  for  compression  of  spinal 
cord,  530 

Power,  Anatomy  of  Arteries,  notice  of,  178 
Pregnancy,  can  it  follow  rape,  272 
Pregnant  uterus,  retroversion  of,  253 
Premature  delivery  with  rare  presentation, 
77 

Pyaemia,  primary,  67 


R. 

Radcliffe,  epidemic  diseases  in  Great  Britain 

in  1861  and  1862,  522 
Rape  during  sleep,  261 

 ,  can  pregnancy  follow,  272 

Retroversion  of  pregnant  uterus,  253 
 uterus,  Hodge's  pessary  for, 

254 
Reviews — 

 Chamber's  Clinical  Lectures  on  Re- 
storative System  of  Medicine,  387 

 Gairdner's  Clinical  Medicine,  403 

 Guy's  Hospital  Reports,  125 

 Holmes'  Surgery,  408 

 Medico-Chirurgical  Transactions,  394 

 Report  of  Commission  for  Improving 

Sanitary  Condition  of  Barracks  and  Hos- 
pitals, 112 

 Salter  on  Asthma,  97 

 Selected  Monographs  of  New  Syden- 
ham Society,  121 

 Smith  on  Consumption,  91 

Rheumatic  pericarditis  and  endo-carditis, 
207 

Richardson,  luxation  of  head  of  fibula,  385 
Roger,  generalized  emphysema,  488 
Rupture  of  heart  attributed  to  violence,  521 
Ruschenberger,  oakum  as  a  substitute  for 
lint,  268 

S. 

Salisbury,  cholesterine  and  seroline  as  secre- 
tions, 289 
Salter  on  Asthma,  review  of,  97 
Sandham,  electro-galvanism,  191 
Sawyer,  unusual  density  of  amnion,  517 
Scattergood,  active  principles  of  veratrum 

viride,  529 
Schroder,  spontaneous  generation,  459 
Sharpey's  Address,  notice  of,  173 
Short,  Dr.  C.  W.,  obituary  notice  of,  635 
Sidey,  cause  of  delay  in  labour,  246 
Silver  wire  ligatures,  373 
Sim,  dislocation  of  ensiform  cartilage  during 

pregnancy,  518 
Smart,  effect  of  diet  and  drugs  on  diabetes 
mellitus,  492 


Smith,  conditions  affecting  constitution  of 

phthisical  persons,  482 

 ,  formula  for  solution  of  bromine,  385 

 ,  horse-hair  for  sutures,  227 

 on  consumption,  review  of,  91 

Spence,  portion  of  food  impacted  in  larynx, 

222 

— — — ,  tracheotomy  tube  in  bronchus,  220 
Spense,  amputation  of  hip-joint  for  malig- 
nant disease,  507 
Spina  bifida,  sac  of  removed,  510 
Spinal  cord,  operation  for  compression  of, 
530 

Spleen,  enormous,  489 
Spontaneous  generation,  459 
Stereoscopic  theory  of  vision,  128 
Sterno-cleido-mastoid   muscle,  induration 
of,  519 

Storer's  Dictionary  of  Solubility  of  Chemical 
Substances,  notice  of,  430 

Strychnia,  internal  exhibition  of,  464  . 

 ,  nicotia  in  poisoning  by,  220 

 ,  tannin  as  antidote  to,  258 

Subclavian,  ligation  of,  70,  266 

Subcutaneous  treatment  of  boils  and  carbun- 
cles, 222 

Supra-pelvic  hematocele,  519 

Supra-renal  capsules,  disease  of,  125 

 ,   disease   of,  without 

bronzing  of  skin,  489 

 ,  physiology  and  patho- 
logy of,  207 

Surgeon-General  U.  S.  A.,  circular,  527 

 ,  report,  532 

Surgical  cases,  Ashhurst,  342 

Sutures,  wire,  226 

 ,  horse-hair,  227 

Syphilitic  affections  of  visions,  240 

Syrup  of  carbonate  of  iron,  190 


T. 

Taenia  treated  by  areca  nut,  496 
Tannin,  antidote  to  strychnia,  258 
Tartrate  of  antimony  as  an  oxytoxic,  513 
Taylor,  bronzed  skin,  208 
,  placenta  praevia,  78 

 ,  syphilitic  affections  of  vision,  240 

Tetanus  and  paralysis,  coexistent,  82 

 ,  nicotia  in,  220 

 ,  nicotine  in  traumatic,  496 

Thigh,  white  fibro-serous  discharge  from, 
491 

Thomas,  ovarian  dropsy  cured  by  iodine  in- 
jections, 376 

Thoracentesis  in  pleuritic  effusions,  202 

Thorp,  encysted  tumours,  229 

 ,  paracentesis  in  pleuritic  effusions 

202 

Tibia,  gunshot  injury  of,  218 
Tissue  change,  action  of  iron  on,  461 
Tobacco  as  a  cause  of  angina  pectoris,  205 

 ,  use  and  abuse  of,  457 

Toronto,  notice  of  report  of  Insane  Hospital 
at,  432 

Toscani,  poisoning  by  bitter  almonds  with 

iodide  of  iron,  261 
Tracheotomy,  new  method  of  performing,  63 

 — —  for  croup,  269 

 tube  in  bronchus,  220 

Transfusion  apparatus,  248 


/ 


542  Ind 

Triquet,  dangers  of  catheterism  of  Eusta- 
chian tube,  224 

Trismus  nascentium,  51 

Trousseau,  fermentative  theory  of  disease, 
471 

 ,  clubbed  fingers,  487 

Tschepke,  poisoning  by  strychnia,  morphia, 

chloroform,  &c,  259 
Tufnell,  gunshot  injury  of  tibia,  fracture  of 

femur,  218 
Tumour  at  base  of  brain,  127 
Tumours,  encysted,  229 

 ,  fibrous,  of  iliac  fossae,  231 

Turner,  use  of  antimonii  et  pot.  tartr.  and 

croton  oil  in  varicose  veins,  382 
Twin  births,  repeated,  251 
Typhoid  fever,  treatment  of,  193 
Typhus  and  typhoid  fevers  in  Dublin,  192 

 in  Iceland,  194 

 ,  disinfecting  treatment  of,  196 

Tyrone,  stereoscopic  theory  of  vision,  128 

U. 

Uraemic  poisoning,  carbonate  of  ammonia  in 

blood  in,  210 
Urinary  bladder,  cysts  in,  211 

 ,  inversion  of,  213 

Urinary  organs,  diseases  of,  131 
Urine  in  hydrophobia,  492 

  diseases  of  bones,  508 

Uterine  polypi,  131 
Uterus,  rupture  of,  272 

V. 

Vaginal  lithotomy,  511 

Van  Deen,  action  of  electricity  in  metamor- 
phosis of  organic  substances,  460 

Van  der  Kolk,  atrophy  of  brain,  notice  of, 
123 

Varicose  veins,  use  of  antimonii  tartras,  and 

ol.  tiglii  for,  382 
Veratrum  viride,  active  principles  of,  529 
Vermont,  registration  reports  of,  notice  of. 

424 


EX. 

Verruca  necrogenica,  213 
Vesical  calculi,  cases  of,  85 
Vinegar  as  an  antiscorbutic,  267 
Vision,  affections  of,  apparently  from  syphi- 
lis, 240 

 ,  stereoscopic  theory  of,  128 

 ,  double,  528 

Voltaic  current,  permanent,  190 
Von  Dusch  on  thrombus  in  superior  longitu- 
dinal sinus,  notice  of,  122 
Vulpian,  deep  origin  of  facial  nerve,  183 

W. 

Wales,  gunshot  wound  of  chest  and  abdo- 
men, 380 
Walshe's  Address,  notice  of,  170 
Walter,  foreign  bodies  in  air-passages,  56 
Water,  diseases  produced  by  bad,  475 
Western  Pennsylvania  Asylum  for  Insane, 

notice  of  report  of,  152 
White,  black  calculus  from  kidney,  270 
Whooping-cough  cured  by  chestnut  leaves, 
528 

Wilbrand,  haemine  crystals  in  different  ani- 
mals, 259 

Wiles,  morbus  Addisonii,  208 

Wilks,  disease  of  supra-renal  capsules,  125 

 ,  verruca  necrogenica,  213 

Willet,  diabetes  mellitus  ending  in  phthisis, 
209 

Wilson  on  diseases  of  the  skin,  notice  of,  441 
 ,  sac  of  spina  bifida  removed  by  opera- 
tion, 510 

Winterbotham,  poisoning  by  morphia,  520 
Wire  compress  as  a  substitute  for  the  liga- 
ture, 500 

Woodward's  Hospital  Steward's  Manual, 

notice  of,  182 
Wormald,  necrosis,  232 
Wyman,  poisoning  by  pollen  of  tiger  lily, 

271 

Y. 

Yeo,  ovariotomy,  511 


American  Journal  of  Med.  Sciences. 


543 


GRADUATES  OF  JEFFERSON  MEDICAL  COLLEGE  OF  PHILADELPHIA, 

March,  1863. 


At  a  Public  Commencement,  held  on  the  10th  of  March,  1863,  the  degree  of  Doctor 
of  Medicine  was  conferred  on  the  following  gentlemen  by  the  Hon.  Edward  King, 
LL.  D.,  President  of  the  Institution  ;  after  which  a  Valedictory  Address  to  the 
Graduates  was  delivered  by  Prof.  Wallace. 


NAME. 

Albert,  David 
Applegate,  Frederick  C. 

Barndt,  Solomon  K. 

Bauduy,  Jerome  Keating 

Beach,  William  T. 
Boyd,  George  B. 
Boughman,  George  W. 
Bradley,  John 

Brittain,  Richard  James 

Brown,  Richard  E. 

Cad  well,  Joseph  W. 
Campbell,  Thomas  F. 
Canfield,  Ira  D.,  Jr. 
Clark,  Vachal  M. 
Carroll,  William 
Clarke,  George  W. 
Coles,  John  W. 
Coover,  Joseph  H. 
Corbit,  William  B. 

Crawford,  Cornelius  C.  V.  A. 

Crosby,  James  A. 

Dayton,  Samuel  W. 
De  Witt,  John  Wilson 
Donor,  William  J. 


STATE  OR  COUNTRY. 

Pennsylvania. 
Ohio. 


SUBJECT  OF  THESIS. 


Pennsylvania. 

Pennsylvania. 

Pennsylvania. 
Pennsylvania. 
Delaware. 
Pennsylvania. 

Pennsylvania. 

New  Jersey. 

Illinois. 

Pennsylvania. 

Pennsylvania. 

Tennessee. 

Pennsylvania. 

Nova  Scotia. 

New  Jersey. 

Pennsylvania. 

Delaware. 

Pennsylvania. 

Kentucky. 

Pennsylvania. 
Pennsylvania. 
Canada  West. 


Dougherty,  Matthew  C.  Virginia 


Eagleson,  David  S. 
Etter,  D.  Frank 

Fawcett,  Charles  L. 
Foote,  Herschel 
Ford,  William  H. 
Free,  Jared 

Gale,  John  Witten 
Gerry,  James,  Jr. 
Griffith,  David  S. 

Handrick,  Edgar  L. 

Hays,  William  L. 

Huff,  Isaac 
Huston,  John  M. 

Johnson,  Charles  M. 

Kelly,  William  R. 

Lehr,  George  Y. 
Lightner,  Samuel  B. 
Loller,  William  B. 


Pennsylvania. 
Pennsylvania. 

Ohio. 

Pennsylvania. 
Pennsylvania. 
Pennsylvania. 

Ohio. 

Pennsylvania. 
Pennsylvania. 

Pennsylvania. 

Maryland. 

Pennsylvania. 
Pennsylvania. 

New  York. 

Ohio. 

Pennsylvania. 
Pennsylvania. 
Ohio. 


Acute  Dysentery. 
Pustule  Maligne. 

Fever. 

(  Erysipelas  as  connected  with  Gunshot 
(  Wounds. 
Fractures. 

Report  of  Hospital  Cases. 

Anatomy  of  the  Eye. 

Fractures, 
f  The  Requisites  and  True  Aims  of  an 
(    M.D.  . 

Chronic  Rheumatism. 

Gunshot  Wounds. 

Puerperal  Fever. 

Hydrops. 

Typhoid  Fever. 

Gonorrhoea. 

Medical  Physiognomy. 

Scorbutus. 

Phrenology. 

Hybridism  of  Diseases, 
f  Ovulation  the  True  Sexuality  of  Wo- 
\  man. 

Typhoid  Fever. 

Functions  of  the  Spleen. 

Intermittent  Fever. 

Intermittent  Fever. 
/  Typhoid  Fever  of  Mountainous  Re- 
(  gions. 

Typhoid  Fever. 

Gunshot  Wounds. 

The  Doctor. 
Enteric  Fever. 

Gunshot  Wounds  of  the  Chest. 
Placenta  Prsevia. 

Sporadic  Cholera. 

Diphtheria. 

Diphtheria. 

Pneumonia, 
f  Fever  the  Result  of  Perversion  of 
(  Function. 

Typhoid  Fever. 

Diphtheria. 

Diphtheria. 

Hospital  Gangrene. 

Dysentery.  , 
Phthisis  Pulmonalis. 
Scarlatina. 


I 


544 


American  Journal  of  Med.  Sciences. 


Longwill,  Robert  L. 
Loper,  William  F. 

Mackey,  James  W. 
Maines,  Robert  G. 
Marshall,  Robert  C. 
McCandless,  Jas.  Newton 
McCandless,  Josiah  G. 
McDonough,  James 


STATE  OR  COUNTRY.  SUBJECT  OF  THESIS, 

Pennsylvania.      Gunshot  Wounds. 
New  Jersey.-  Pyseniia. 


Pennsylvania. 
New  Jersey. 
Pennsylvania. 
Pennsylvania. 
Pennsylvania. 
Pennsylvania. 

Pennsylvania. 

Morrison,  John B.  G.  (M.  D.)  Nova  Scotia. 
Murphy,  Samuel  M.  Pennsylvania. 


Pigott,  Charles  J. 
Pulsifer,  Horatio  B. 


Pennsylvania. 
Pennsylvania. 


Reber,  William  Mi  Pennsylvania. 

Richards,  Daniel  W.  Pennsylvania. 

Rittenhouse,  George  W.  New  Jersey. 

Robinson,  Charles  Canada  West. 


Rubeola. 
Dysentery. 
Opium. 
Scarlet  Fever. 
Enteric  Fever. 
Inflammation. 

[  Anatomical  Structure  of  Adam  and 
[  Eve. 

Tartar  Emetic. 

Soarlatina. 

Enteric  Fever. 
Variola. 

Typhoid  Pneumonia. 
Inguinal  Hernia. 
Inguinal  Hernia. 
Phthisis. 


Sackrider,  Charles  H.  (M.  D.)  Michigan.         Extracting  Teeth. 


Say,  Eli  J. 
Seiler,  Robert  H. 
Snively,  I.  N. 
Stephenson,  Robt.  Amasa 
Stewart,  William  S. 
Stone,  Brinton 
Stubbs,  Charles  H. 

Terry,  Henry  R. 
Townsend,  Ellis  P. 
Trumbauer,  Henry  T. 
Tuft,  Reuben  H. 
Turnbull,  John 
Turner,  Theophilus  H. 

Vaill,  Charles  H. 

Way,  Walter  R. 
Whitford,  Lorenzo  D. 
Wiles,  C.  Hamer 
Williams,  Abraham  D. 
Willson,  David  B. 
Wilson,  Charles  P. 
Woods,  James  M.  B. 


Pennsylvania.  Alcoholic  Liquors. 

Pennsylvania.  Gunshot  Wounds. 

Pennsylvania.  Diphtheria. 

Ohio.  Scurvy. 

Pennsylvania.  Podophyllin. 

Pennsylvania.  Observations  on  Surgical  Injuries. 

Pennsylvania.  Acute  Rheumatism. 

Pennsylvania.  Dyspepsia. 

Pennsylvania.  Variola. 

Pennsylvania.  Acute  Pleuritis. 

Maryland.  Spasmodic  Asthma. 

Ohio.  Signs  of  Pregnancy. 

New  Jersey.  Opium. 

Connecticut.  Gunshot  Wounds. 

Pennsylvania.  Camp  Fever. 

Ohio.  Acute  Rheumatism. 

Ohio.  Inflammation. 

Ohio.  Dacryocystitis. 

Pennsylvania.  Humulus  Lupulus. 

Ohio.  Typhoid  Fever. 

Canada  West.  Influence  of  Climate  on  Disease. 


Of  the  above,  there  are  from — 

Pennsylvania      ........  49 

Ohio   11 

New  Jersey   6 

Canada  West   3 

Delaware   2 

Maryland   2 


Nova  Scotia 

Illinois 

Kentucky 

Tennessee 

Virginia 

New  York 

Michigan 

Connecticut 


Total 


82 


Date  Due 


1863 

American  .journal  v»45-N.S. 
of  the  medical  sciences 


ISSUED  TO 


JOUfUAl 

of  rug 

new  sems 
vol.  1S. 


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